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Prader-Willi Syndrome (PWS) is a rare genetic disorder associated with emotional/behavioral disturbances. These difficulties are well documented in the literature, but the positive attributes of these individuals are not described. Taking a strengths-based approach, the aim of this study was to describe the emotional/behavioral strengths and difficulties in children and young people with PWS from their parent caregivers' perspectives. Parent caregivers of 52 individuals with PWS aged 4-24 years (median = 12.1 years; including 22 males) completed the parent form of the Developmental Behavior Checklist (DBC-P), including its original two open-ended questions regarding positive traits. Prevalences of emotional/behavioral disturbances were comparable to those reported in previous literature: common behaviors of concern across studies being skin-picking (75%), impulsivity (69%), poor sense of danger (67%), lying (67%), and tantrums (54%). Total DBC-P scores showed that just over half (n = 28, 54%) had scores indicative of clinically significant behavior problems. However, thematic analysis of caregivers' written comments regarding their children's strengths resolved into three themes: warmth (94%), persistence (41%), and skills (41%). Warmth encompassed friendliness, happiness, and empathy. A strength-based approach to behavioral difficulties in PWS provides a more balanced view of the children and a more holistic foundation for interventions., (© 2022 Wiley Periodicals LLC.)

Aim: Pulse oximetry has become a widely used technology in medicine and is a standard part of monitoring in neonatal medicine. Knowledge of basic principles, clinical and technical considerations is important to optimise clinical benefit of use, but have been shown to be insufficient in paediatric staff. We aimed to assess knowledge of pulse oximetry in neonatal medical staff, a population not previously studied., Methods: A 21-item questionnaire (seven demographic, 14 knowledge) was devised and then administered to neonatal medical staff at all postgraduate levels working in the major public neonatal services in the state of Victoria, Australia., Results: Average test score was 64.4% (range 30.8-92.3%) with no correlation between years of experience and score. All respondents reported experience with oximetry, but only 57% reported adequate training in practical oximetry skills and only 28% in interpretation of downloaded oximetry data. About 45% reported knowing what an averaging time was but only 29% were able to provide an acceptable definition and only 10% knew what averaging time was used on devices in their units., Conclusion: Significant knowledge deficits regarding oximetry are evident in neonatal staff, supporting the need for targeted and continuous training in oximetry., (©2018 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: Preterm infants are at increased risk of Sudden Infant Death Syndrome (SIDS) and frequently experience short central apnoeas which can occur in isolation or a repetitive pattern (periodic breathing). We investigated the relationship between central apnoeas experienced before and over the 6 months after hospital discharge and cerebral oxygenation., Methods: Preterm infants born between 28 and 32 weeks gestational age (GA) were studied during supine daytime sleep at 32-36 weeks post menstrual age (PMA) (n = 40), 36-40 weeks PMA (n = 27), 3-months corrected age (CA) (n = 20) and 6-months CA (n = 26). Cerebral tissue oxygenation (TOI), peripheral oxygenation (SpO 2 ) and heart rate were recorded continuously. The percentage total sleep time (%TST) spent having central apnoeas at each study and cerebral fractional oxygen extraction (SpO 2 -TOI/SpO 2 ) were calculated., Results: %TST spent with central apnoeas decreased with increasing age in both active sleep (AS) and quiet sleep (QS). TOI tended to be lower and cerebral fractional oxygen extraction higher at 3 months compared to the other studies and this reached statistical significance compared to 32-36 weeks in QS., Conclusion: The nadir in cerebral tissue oxygenation at 3 months of age coincides with the peak risk period for SIDS and this may contribute to increased risk in these infants., (© 2024 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Aim: Preterm infants frequently experience short apnoeas and periodic breathing. Animal studies have shown that repetitive hypoxia associated with periodic breathing can alter autonomic control. We aimed to elucidate if apnoea and periodic breathing were associated with changes in autonomic control assessed using heart rate variability, thus exacerbating the consequences of respiratory disturbance., Methods: Forty very preterm infants (15 M/25 F) were studied at 34.3 weeks post-menstrual age with daytime polysomnography. Total power, low frequency (LF, sympathetic+parasympathetic activity) high frequency (HF, parasympathetic activity) and LF/HF (sympathovagal balance) were calculated., Results: Infants were divided into those with above and below the median total sleep time spent with respiratory events: Active sleep (AS) 13%, Quiet sleep (QS) 10%. In AS, including respiratory events, Total power (p < 0.05) and HF power (p < 0.05) were higher in the above median group. During AS excluding respiratory events, Total power (p < 0.05) and HF power (p = 0.061) were higher and LF power (p < 0.01) and LF/HF (p < 0.05) were lower in the above median group. There were no differences in HRV parameters in QS., Conclusion: This study provides new evidence that short apnoeas, particularly periodic breathing, which is currently not detected or treated in the neonatal unit can affect autonomic cardiovascular control., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Objectives: To determine whether episodes of haemoglobin oxygen (SpO2) desaturation in full-term infants restrained in car seats can be reduced by a simple foam plastic infant car seat insert designed to push the body forward, with space for the protuberant occiput to lie behind the spine, and so reduce flexion of the infant's head on the trunk. Methods: Eighteen healthy full-term babies were evaluated while restrained in an infant car safety seat with, and without, the foam insert. Infants were monitored in each position for 30 min with continuous polygraphic recording of respiratory and heart rate, nasal airflow and SpO2. Results: Placement of the insert in the car seat was associated with a significant reduction in the rate of apneas with a fall in SpO2 >5% (median, interquartile range: 4.4 (0, 10.6) vs. 9.2 (5.4, 15.2) events per hour, p=0.03). The one clinically severe episode of apnea, with a fall in SpO2 of more than 30%, occurred in the car seat without the insert. Conclusions: A car seat insert that allows the newborn's head to lie in a neutral position during sleep may reduce the frequency of mild episodes of reduced SpO2 in some full-term newborn babies. [ABSTRACT FROM AUTHOR]

Objective(s): Hypoglossal nerve stimulation (HGNS) is safe and effective for patients with Down syndrome (DS) and severe persistent obstructive sleep apnea (OSA). Long-term outcomes for this patient population have not been evaluated., Methods: A prospective single-group multicenter cohort study with 1-year follow-up was conducted between 2015 and 2021 among 42 adolescent patients with DS and severe persistent OSA. Here, we evaluate long-term outcomes in this patient cohort. Patients were evaluated with polysomnogram (PSG) at three timepoints: pre-implantation (timepoint 1), 1-year post-implantation (timepoint 2), and long-term follow-up (timepoint 3)., Results: Long-term follow-up data were available for 33 of 42 patients. Mean (SD) of timepoint 3 was 4.0 (1.9) years after implantation. Using a therapy response definition of a 50% decrease in Apnea Hypopnea INdez (AHI) from timepoint 1, the response rate was 69.7% (23/33) at timepoint 2 and 87.9% (29/33) at timepoint 3. From timepoint 1, there was a mean (SD) decrease in AHI of 12.7 (13.4) events/h at timepoint 2 and 15.7 (13.1) events/h at timepoint 3. The mean percentage change in AHI between timepoints 1 and 2 was -51.1% (95% CI: -32.8% to -69.3%) and between timepoints 1 and 3 was -59.6% (95% CI: -42.0% to -77.3%)., Conclusion: Patients with DS and severe persistent OSA who undergo HGNS implantation may continue to experience improvement in PSG parameters at long-term follow-up. Future studies are needed to assess additional long-term outcomes in this patient population, including neurocognition and quality of life., Level of Evidence: 3 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Assess the risks and benefits of adenotonsillectomy (AT) for obstructive sleep apnea (OSA) in children with cerebral palsy (CP)., Study Design: Systematic review., Methods: We conducted a systematic review of Medline, Embase, and Cochrane Central Registry from 1946 to 2021. Broad search concepts included cerebral palsy, pediatric, tonsillectomy/adenoidectomy, and sleep. Additional articles were identified by searching reference lists. Studies on the safety and efficacy of AT for OSA management in children with CP were included., Results: Fifteen articles met inclusion criteria. Articles were classified into one or more of four themes: intraoperative risk (n = 1), postoperative risk (n = 3), postoperative care requirements (n = 6), and surgical outcomes (n = 7). No intraoperative anesthetic complications were reported. Postoperatively, respiratory complications including pneumonia were common and necessitated additional airway management. Following AT, children with CP required close postoperative observation, experienced increased lengths of stay, and had increased odds of unplanned intensive care unit (ICU) admission. Benefits following AT were improvement in OSA as measured by a reduction in obstructive apnea-hypopnea index (OAHI) as well as improved quality of life in some; however, many patients went on to require tracheostomy due to persistent OSA., Conclusions: Children with CP who undergo AT have a significant risk of developing a postoperative respiratory complication. Realistic counseling of families around increased perioperative risks in this population is imperative and close postoperative monitoring is critical. Many children will obtain a reduction in OAHI, but additional surgical management is often required, including tracheostomy. Further research is needed to determine the best management strategy for OSA in children with CP. Laryngoscope, 132:687-694, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Autonomic dysfunction is an independent risk factor for cardiovascular disease (CVD). Both obesity and obstructive sleep apnea (OSA) are associated with heart rate variability (HRV) (a hall marker of sympathetic arousal) and increased risk of CVD. This study aims to investigate whether anthropometric parameters could predict reduced HRV in adult OSA during wakefulness. Study Design: Cross‐sectional study. Setting: Sleep center of Shanghai Jiao Tong University Affiliated Sixth Hospital from 2012 to 2017. Methods: Total of 2134 subjects (503 non‐OSA and 1631 OSA) were included. Anthropometric parameters were recorded. HRV was recorded during a 5‐minute wakefulness period and analyzed by using time‐domain method and frequency‐domain method. Multiple step‐wise linear regressions were performed to determine significant predictors of HRV with and without adjustments. Multiplicative interactions between gender, OSA, and obesity on HRV were also determined and evaluated. Results: Waist circumference (WC) was significant negative determinant of root mean square of successive NN intervals (β = −.116, p <.001) and high‐frequency power (β = −.155, p <.001). Age was the strongest determining factor of HRV. Significant multiplicative interactions between obesity and OSA on HRV, gender, and obesity on cardiovascular parameters were observed. Conclusion: Anthropometric parameters could predict reduced HRV during wakefulness in patients with OSA, especially WC was the strongest influenceable factor. Obesity and OSA had significant multiplicative interaction on HRV. Gender and obesity had significant multiplicative interaction on cardiovascular parameters. Early intervention for obesity, especially centripetal obesity, may improve reduction of autonomic function and risk of CVD. [ABSTRACT FROM AUTHOR]

Objective: (1) Compare proportions of collapse, obstruction, or mixed instances on drug‐induced sleep endoscopy findings of obese and nonobese children with obstructive sleep disordered breathing. (2) Determine the frequency of collapse in general between both groups. Study Design: Retrospective case‐control study. Setting: Tertiary pediatric center. Methods: Obese (body mass index >95 percentile) children presenting with obstructive sleep disordered breathing (>33 on the pediatric sleep questionnaire) were identified from a prospectively kept surgical database. Only those who had undergone drug‐induced sleep endoscopy were eligible. Age and sex pair‐matched nonobese children were identified. Only nonsyndromic, neurologically normal, surgically naïve patients were included. The frequency of obstructive, collapse, and mixed pharyngeal patterns was documented in both groups. A comparison of proportions was then undertaken (χ2 test). Results: Over a 5‐year period, 73 consecutive children with obesity were identified (40 males; mean of 8.5 ± 3.0 years, 2.8‐13.1). They were matched with 73 nonobese children (8.4 ± 3.0 years, 2.6‐14.1). The obese group exhibited significantly more pharyngeal collapses (62:47) (p =.0021 odds ratio [OR] 3.358, 95% confidence interval [CI] 1.52‐7.42). The proportion of pharyngeal findings on drug‐induced sleep endoscopy was significantly different (p =.000129) between the 2 groups; obese (61 mixed: 3 obstruction: 9 collapse) and nonobese (48 mixed: 22 obstruction: 4 collapse). Conclusion: The predominance of hypopharyngeal collapse in children with obesity may explain the likelihood of failure of surgery directed at obstructive findings. This may also strengthen the case for drug‐induced sleep endoscopy in this group at the initial surgery to guide it rather than after the failure of adenotonsillectomy. [ABSTRACT FROM AUTHOR]

We appreciate Friedman et al. for their study, in which they aimed to determine the criteria indicating the necessity of hospitalization on the first postoperative night in children who underwent adenotonsillectomy (TA) surgery for obstructive sleep-respiratory disorder.[1] We want to express our views on postoperative respiratory complications that cause death in one out of 10,000 children undergoing TA surgery in the United States and present some criticisms of the authors' study.[2] The authors stated that children who need oxygen support for less than 3 h after TA surgery and sleep while breathing room air but do not experience desaturation can be safely discharged regardless of their comorbidities and polysomnography results. Indeed, otolaryngology and pediatric clinical practice guidelines have only aimed to identify pediatric patients at high risk for respiratory complications who require hospitalization after TA surgery. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. [Extracted from the article]

Objectives: Prader-Willi syndrome (PWS) increases the risk of obstructive sleep apnea (OSA) due to obesity, hypotonia, and abnormal ventilatory responses. We evaluated post-adenotonsillectomy complications, polysomnography changes, and quality of life in children with OSA and PWS., Study Design: Systematic review and meta-analysis., Methods: We conducted a systematic review and meta-analysis by searching PubMed, Embase, Cochrane, Web of Science, and Scopus. Two researchers independently reviewed studies about adenotonsillectomy for OSA in patients <21 years with PWS. We extracted study design, patient numbers, age, complications, polysomnography, and quality of life. We pooled postoperative changes in apnea hypopnea index (AHI) for meta-analysis. We applied Methodological Index for Nonrandomized Studies (MINORS) criteria to assess study quality., Results: The initial search yielded 169 studies. We included 68 patients from eight studies with moderate to high risk of bias. Six studies reported on complications and 12 of 51 patients (24%) had at least one. Velopharyngeal insufficiency was the most commonly reported complication (7/51, 14%). We included seven studies in meta-analysis. Mean postoperative improvement in AHI was 7.7 (95% CI: 4.9-10.5). Postoperatively 20% (95% CI: 3%-43%) had resolution of OSA with AHI < 1.5 while 67% (95% CI: 50%-82%) had improvement from severe/moderate OSA to mild/resolved (AHI < 5). Two studies evaluated quality of life and demonstrated improvement., Conclusions: Children with PWS undergoing adenotonsillectomy for OSA have a substantial risk of postoperative complications that may require additional interventions, especially velopharyngeal insufficiency. Despite improvements in polysomnography and quality of life, many patients had residual OSA. This information can be used to counsel families when considering OSA treatment options. Laryngoscope, 131:898-906, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Obesity is a risk factor for obstructive sleep apnea (OSA) in children. Childhood obesity rates vary amongst different ethnic groups. Here the interaction of Hispanic ethnicity and obesity on OSA risk was evaluated. Methods: Retrospective cross‐sectional analysis of consecutive children undergoing polysomnography and anthropometry using bioelectrical impedance from 2017 to 2020. Demographics obtained from the medical chart. Children who had also undergone cardiometabolic testing were identified and the relationship of cardiometabolic markers with OSA and anthropometry was assessed. Results: Data from 1217 children revealed Hispanic children were more likely to have moderate‐severe OSA (36.0%) compared to Non‐Hispanic children (26.5%), p < 0.001. Hispanic children had greater Body mass index (BMI), BMI percentile and percent body fat, p < 0.0001. In children that underwent cardiometabolic testing, Hispanic children had significantly greater serum alanine aminotransferase levels (ALT) levels. Following adjustment of age and sex, Hispanic ethnicity was not found to moderate the association of anthropometry with OSA, anthropometry with cardiometabolic markers, and OSA with cardiometabolic markers. Conclusions: OSA was more likely in Hispanic children; this relationship was likely driven by obesity status rather than ethnicity. Among children undergoing cardiometabolic testing, Hispanic children were observed to have greater ALT concentrations however ethnicity did not impact the association of anthropometry and ALT or other cardiometabolic markers. [ABSTRACT FROM AUTHOR]

Objective: Few data are available to guide postadenotonsillectomy (AT) pediatric intensive care (PICU) admission. The aim of this study of children with a preoperative polysomnogram (PSG) was to assess whether preoperative information may predict severe respiratory events (SRE) after AT. Study Design: Retrospective cohort study. Setting: Single tertiary center. Methods: Children aged 6 months to 17 years who underwent AT with preoperative polysomnography (2012‐2018) were identified by billing codes. Data were extracted from medical records. SRE were defined as any 1 or more of desaturations <80% requiring intervention; newly initiated positive airway pressure; postoperative intubation; pneumonia/pneumonitis; respiratory code, cardiac arrest, or death. We hypothesized that SRE would be associated with age <24 months, major medical comorbidity, obesity (>95th percentile), apnea‐hypopnea index (AHI) ≥ 30, and O2 nadir <70% on PSG. Analysis was performed with multivariable logistic regression. Results: Of 1774 subjects, 28 (1.7%) experienced SRE. Compared to those without, children with SRE were on average younger (3 vs 5 years, p <.01) with a greater probability of medical comorbidities (59% vs 18%, p <.001). After adjustment for sex, black race, obesity, and age <24 months, children with major medical comorbidity were more likely than other children to have SRE (odds ratio [OR]: 14.2; 95% confidence interval [CI]: [5.7, 35.2]), as were children with AHI ≥ 30 (OR: 7.7 [3.0, 19.9]), or O2 nadir <70% (OR 6.1 [2.1, 17.9]). Age, obesity, sex, and black race did not independently predict SRE. Conclusion: PICU admission may be most prudent for children with complex medical co‐morbidities, high AHI (>30), and/or low O2 nadir (<70%). [ABSTRACT FROM AUTHOR]

Objective: The purpose of the study was to determine if the intra‐alveolar Aloe vera extract powder could reduce the incidence of alveolar osteitis (Dry socket) following extraction in the premolar site. Materials and methods: This trial was a double‐blinded randomized controlled clinical study with a split‐mouth design which included 40 premolars sockets in 20 adult patients, aged 25–49 years. Each patient had two symmetrical extraction sites. The study sample was randomly allocated into two groups (A) the Aloe vera group, and group (B) the control group, extractions were performed for both sides in the same appointment. The occurrence of dry sockets was recorded on the third and seventh days after the extraction. Also, post‐extraction pain scores and the healing of the extraction socket were assessed. Results: The Aloe vera group showed a lower post‐extraction alveolar osteitis (dry socket) occurrence compared with the control group with a statistically significant difference (p < 0.05). The results also showed a decrease in pain scores in the experimental group compared to the control group with statistically significant differences on the first, third and seventh day after extraction (p < 0.05). Also, there were statistically significant differences in the degrees of healing of the extraction socket between the two groups on the seventh day after extraction (p < 0.05). Conclusion: It was concluded that the topical application of Aloe vera extract powder intra‐alveolar after extraction may decrease the incidence of alveolar osteitis (dry socket), improve socket healing and reduce post‐extraction pain. [ABSTRACT FROM AUTHOR]

Objective: Solid‐organ transplantation (SOT) has become the standard of care for children with terminal organ failure. Long‐term immunosuppression has improved survival substantially but is associated with secondary malignancies and impaired wound healing. Our goal was to review the incidence, outcomes, complications, and rate of posttransplant lymphoproliferative disorder on pathologic examination following tonsillectomy/adenotonsillectomy (T/AT) in children after SOT. Study Design: A retrospective cohort study. Setting: Tertiary care children's hospital. Methods: Data were extracted from charts of children with a history of kidney, heart, or liver transplantation, who underwent T/AT between 2006 and 2021. Results: A total of 110 patients met the inclusion criteria, including 46 hearts, 41 kidneys, 19 livers, and 4 liver‐and‐kidney transplants. The mean age at transplantation was 4.2 years, and the mean transplantation‐to‐T/AT time interval was 28.8 months. The posttransplant lymphoproliferative disorder was diagnosed in 52 (47.3%) patients, and 25% of these had no tonsillar hypertrophy. There was no difference in age at transplantation, organ received, transplantation‐to‐T/AT time interval, immunosuppressive medications, tonsil size, or tonsillar asymmetry between patients diagnosed with the posttransplant lymphoproliferative disorder and patients with benign tonsillar/adenotonsillar hypertrophy. Posttonsillectomy complications were similar between the groups. Conclusion: The incidence of posttransplant lymphoproliferative disorder undergoing tonsillectomy for any indication was 47.3%. There was no association between preoperative signs and symptoms and the histopathological diagnosis of posttransplant lymphoproliferative disorder. Stratification by organ received and immunosuppressive medications did not identify differences among the groups relative to the incidence of posttransplant lymphoproliferative disorder and other postoperative complications. [ABSTRACT FROM AUTHOR]

Objective: Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals., Study Design: Quality improvement initiative., Methods: Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU., Results: In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability., Conclusions: Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity., Level of Evidence: N/A Laryngoscope, 131:S1-S10, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Background and Aims: A chronic feeling of fatigue occurs in up to 85% of childhood cancer survivors (CCS). This phenomenon has a detrimental effect on quality of life, reintegration in daily life activities and psychosocial functioning of the patient. Therefore, it is important to elucidate potential individual risk and protective factors. Methods: CCS who were treated in the University Hospital of Leuven, completed two annual questionnaires on cancer‐related distress (fear of cancer recurrence and post‐traumatic stress, resilience and fatigue). Associations between distress and fatigue levels were examined by performing cross‐lagged panel analyses. Resilience was included as a potential moderator. These models included all within‐time associations, stability paths, and cross‐lagged paths. Gender and time since diagnosis were included as covariates. Results: In total, 110 CCS participated in this study, aged 14–25 years (average time since diagnosis 12.2 years; 41.8% boys; diagnosed with leukemia/lymphoma [49%], solid tumor [15%], brain tumor [16%] or other [20%]). Fear of cancer recurrence and post‐traumatic stress at baseline positively predicted fatigue 1 year later. Cross‐lagged panel analyses showed that resilience did not buffer the effect of fear of cancer recurrence on fatigue, in contrary to our expectations. Stability coefficients were high for all study variables. Conclusion: This study indicates associations between cancer‐related distress (fear of cancer recurrence and post‐traumatic stress), resilience and cancer‐related fatigue over time in CCS. Interventions to improve fatigue levels could be focusing on both tackling cancer‐related distress, while improving resilience levels as well. [ABSTRACT FROM AUTHOR]

Aim: Despite a recent increase in the use of ventilators in the home setting for children with chronic respiratory failure, there is currently no unified approach for clinical decision‐making for children requiring long‐term mechanical ventilation. The purpose of this study is to understand the clinician's perspective on decision‐making around home ventilation for children, and how home‐based care contributes to successful outcomes in this population. Methods: We recruited physicians and home ventilation nurses with at least 2 years' experience working in an Australian paediatric tertiary home ventilation service using professional networks and snowball sampling. Semi‐structured interviews were conducted by two researchers between February 2019 and June 2020. Interviews were audio‐recorded, transcribed, and analysed using inductive content analysis. Results: Twenty‐five individuals participated (17 physicians and 8 home ventilation nurses). Participants viewed themselves as impartial medical advocates in the decision‐making process, believing the decision to initiate or cease ventilation belonged to the child's family. While participants held the child's quality of life as the cornerstone of decision‐making, quality of life was subjective and family specific. Conclusion: These findings provide insight into how clinicians working with children with chronic respiratory insufficiency approach the decision to introduce home‐based ventilation. By understanding their role, strategies can be developed to assist them, leading to better outcomes for patients and families. Further research is needed to compare the perspectives of clinicians with the experience of ventilator‐assisted children and families in Australia. [ABSTRACT FROM AUTHOR]

Aim: No studies have described long-term paediatric home respiratory support in Nordic countries. We examined the clinical characteristics and long-term outcomes of paediatric patients who received continuous positive airway pressure, non-invasive-positive-pressure ventilation and invasive ventilation from a multidisciplinary home respiratory support team., Methods: Retrospective tertiary-level data were collected between 1 January 2010 and 31 December 2020 in Tampere University Hospital. These comprised patient demographics, treatment course and polysomnography-confirmed sleep-disordered breathing (SDB)., Results: There were 93 patients (63.4% boys). The median age at treatment initiation was 8.4 (range 0.11-16.9) years. The patients had: neuromuscular disease (16.1%), central nervous system disease (14.0%), developmental disabilities and congenital syndrome (29.0%), lung-airway conditions (11.8%), craniofacial syndrome (15.1%) and severe obesity (14.0%). More than two-thirds had severe SDB (66.7%) and the most common one was obstructive sleep apnoea in 66.7%. We found that 92.5% received long-term therapy for more than 3 months and the mean treatment duration was 3.3 ± 2.7 years. A non-invasive mask interface was used in 94.7% of cases and 5.3% needed tracheostomy ventilation. More than a quarter (26.7%) achieved disease resolution during the study period., Conclusion: Most children who needed long-term home respiratory support had complex conditions and severe, persistent SDB., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

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It is increasingly recognized that children with asthma are at a higher risk of other non‐allergic concurrent diseases than the non‐asthma population. A plethora of recent research has reported on these comorbidities and progress has been made in understanding the mechanisms for comorbidity. The goal of this review was to assess the most recent evidence (2016–2021) on the extent of common comorbidities (obesity, depression and anxiety, neurodevelopmental disorders, sleep disorders and autoimmune diseases) and the latest mechanistic research, highlighting knowledge gaps requiring further investigation. We found that the majority of recent studies from around the world demonstrate that children with asthma are at an increased risk of having at least one of the studied comorbidities. A range of potential mechanisms were identified including common early life risk factors, common genetic factors, causal relationships, asthma medication and embryologic origins. Studies varied in their selection of population, asthma definition and outcome definitions. Next, steps in future studies should include using objective measures of asthma, such as lung function and immunological data, as well as investigating asthma phenotypes and endotypes. Larger complex genetic analyses are needed, including genome‐wide association studies, gene expression–functional as well as pathway analyses or Mendelian randomization techniques; and identification of gene–environment interactions, such as epi‐genetic studies or twin analyses, including omics and early life exposure data. Importantly, research should have relevance to clinical and public health translation including clinical practice, asthma management guidelines and intervention studies aimed at reducing comorbidities. [ABSTRACT FROM AUTHOR]

Background: Severe obstructive sleep apnoea (OSA) is associated with increased risk of respiratory compromise in the post‐operative period following adenotonsillectomy (AT). This study analyses the economic cost of polysomnography or overnight oximetry as part of pre‐operative risk stratification in paediatric AT, supplementing previously published research demonstrating the efficacy of this protocol in predicting respiratory complications. Methods: This cost‐minimisation analysis examines costs associated with pre‐operative overnight oximetry and polysomnography in triaging paediatric patients older than 2 years old, with no major comorbidities except for OSA, undergoing AT for OSA (n = 1801) to either a secondary or quaternary Australian hospital. Decision analysis modelling via probability trees were utilized to estimate pre‐ and peri‐operative costs. A third hypothetical 'no investigation' model based upon conducting all AT at a secondary hospital was performed. Costs are derived from the financial year 2020–2021, censored at discharge. Results: The total cost per patient of AT including pre‐operative investigations of oximetry and polysomnography, and associated inpatient costs, were AUD4181.34 and 5013.99 respectively. This is more expensive compared to a hypothetical no‐investigation model (AUD3958.98). Conclusion: Within the scope of this partial economic evaluation, this study finds a small additional cost for a model of care involving overnight oximetry as a pre‐operative triage tool, balanced by the reduced cost of care in a lower acuity centre for low‐risk patients and potential high cost of complications if all children are treated in a low acuity centre. This supports oximetry in peri‐operative risk stratification for paediatric AT from a financial perspective. [ABSTRACT FROM AUTHOR]

Objectives: Obstructive sleep apnoea (OSA) is a common indication for adenoidectomy and tonsillectomy in children. Traditional practice involves overnight admission to monitor for respiratory complications. However, there is a shift towards same‐day discharge in selected patients. This systematic review aims to critically evaluate day‐case criteria and safety in children with OSA undergoing adenotonsillectomy. Design: We performed a systematic search of EMBASE, Medline and the Cochrane library. All data collected were independently validated for accuracy. Quality assessment of included articles was performed. The protocol was registered with PROSPERO. Results: A total of 15 studies were included (10 731 patients). There was heterogeneity in methods used to ascertain OSA, day‐case discharge criteria and lack of prospective discharge protocol. The proportion of children considered for planned day‐case surgery ranged from 28.7%–100% based on individual criteria, with an average rate of successful same‐day discharge of 96.1% in these patients. The reported rates of post‐operative respiratory adverse events and need for airway intervention were 0%–27.3% and 0.4%–6.8%, respectively. There was no reported mortality. The studies were considered low to medium on quality assessment. Conclusion: There is a lack of prospective data on day‐case criteria and systematic assessment of post‐operative complications in children with OSA undergoing adenoidectomy and tonsillectomy. However, current literature suggests that day‐case surgery is safe in carefully selected patients. Better characterisation of patient‐specific risk factors is needed to develop an optimal criteria‐based timeline for safe discharge. This has the potential to improve confidence and uptake across units. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Children who do not require oxygen beyond 3 hours after surgery and pass a sleep room air challenge (SRAC) are safe for discharge regardless of polysomnogram (PSG) results or comorbidities. Study Design: Cross‐sectional prospective study. Methods: All children observed overnight undergoing an adenotonsillectomy for obstructive sleep‐disordered breathing were prospectively recruited. Demographic, clinical, and PSG characteristics were stratified by whether the patient had required oxygen beyond 3 hours postoperatively (prolonged oxygen requirement [POR]) and compared using t test, chi‐squared test, or Fisher's exact test depending on distribution. Optimal cut points for predicting POR postsurgery were calculated using receiver operating characteristic curves. The primary analysis was performed on the full cohort via logistic regression using POR as the outcome. Significant characteristics were analyzed in a logistic regression model, with significance set at P <.05. Results: A total of 484 participants met the inclusion criteria. The mean age was 5.65 (standard deviation = 4.02) years. Overall, 365 (75%) did not have a POR or any other adverse respiratory event. In multivariable logistic regression, risk factors for POR were an asthma diagnosis (P <.001) and an awake SpO2 <96% (P =.005). The probability of a POR for those without asthma and a SpO2 ≥ 96% was 18% (95% confidence interval: 14–22). Age, obesity, and obstructive apnea/hypopnea index were not associated with POR. Conclusions: In conclusion, all children in our study who are off oxygen within 3 hours of surgery and passed a SRAC were safe for discharge from a respiratory standpoint regardless of age, obesity status, asthma diagnosis, and obstructive apnea/hypopnea index. Additional investigations are necessary to confirm our findings. Level of Evidence: 3 Laryngoscope, 132:1675–1681, 2022 [ABSTRACT FROM AUTHOR]

Background: Our institution implemented a post-anesthesia care unit (PACU) extended-stay model (Grey Zone model), where the post-operative level of care for high-risk adenotonsillectomy patients (general care vs. intensive care unit) was decided based on the clinical course of 2-4 h of PACU admission., Objective: To assess the correlation between post-tonsillectomy respiratory compromise and the need for respiratory support during an extended stay at PACU. To identify comorbidities associated with a need for intensive care after extended observation., Methods: A retrospective cohort study of high-risk children who underwent adenotonsillectomy and were admitted to the Grey Zone following surgery., Results: 274 patients met inclusion criteria. 262 (95.6%) met criteria for general care unit transfer (mean oxygen saturation 94.4 ± 5.1%). Twelve (4.4%) patients were transferred from the PACU to the ICU due to respiratory distress (mean oxygen saturation 86.8 ± 11%). Of the patients admitted to general care, 4 (1.5%) secondarily developed respiratory compromise, requiring escalation of care. Three of these maintained oxygen saturation ≥95% throughout the PACU period. There was no difference between the groups with respect to demographic data, rates of morbid obesity, and severity of obstructive sleep apnea. Neuromuscular disease, chronic lung disease, seizure disorder, and gastrostomy-tube status were more prevalent in those requiring ICU level of care compared to the general care unit., Conclusions: The Grey Zone model accurately identifies patients requiring ICU-level care following adenotonsillectomy, allowing for a safe reduction in the utilization of ICU resources. Due to rare delayed respiratory events, overnight observation in this cohort is recommended., Level of Evidence: 4 Laryngoscope, 133:3582-3587, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Swan Hill District Health (SHDH) provides Otolaryngological services to outer regional Victoria. A preoperative checklist determines eligibility for tonsillectomy, and the role of preoperative investigations such as oximetry. Visiting specialists who provide T&A also remain on‐site for 24 h post‐surgery. Management of post‐discharge complications is supported by SHDH's Emergency Department. Unstable patients are transferred to tertiary care hospitals. This study examines the safety outcomes associated with rural Tonsillectomy and adenotonsillectomy (T&A) and the impact of peri‐operative protocols on these outcomes. Methods: This is a retrospective cohort study of all paediatric (2–18 years old) patients undergoing T&A from August 2014 to June 2020 at SHDH. Four external hospital databases which accept patient transfers from SHDH were searched for T&A‐related complications. The primary outcome was complication incidence. Secondary outcomes were length of stay, and rates of hospital readmissions, return to theatre and inter‐hospital transfer. Results: Two hundred and four patients were included, with median age 6 years old; 68.1% (n = 139/204) had obstructive sleep apnoea, or sleep disordered breathing, wherein 36.0% (n = 50/139) had documented evidence of normal/inconclusive oximetry. The complication rate is 6.9% (n = 14/204), with two intraoperative, five perioperative and seven post‐discharge complications. All intra‐ and peri‐operative complications were managed locally. All post‐discharge complications presented to outer regional EDs. Two patients required inter‐hospital transfer for monitoring of post‐tonsillectomy bleeds in a specialist unit. Conclusions: Patients who pass a preoperative risk checklist can safely undergo T&A in selected rural settings which adhere to strict patient selection criteria and implement safety measures to address complications. [ABSTRACT FROM AUTHOR]

Approximately one in every 700 babies in the United States is born with Down syndrome, or 0.14%. Children with Down syndrome have cognitive impairment and congenital malformations necessitating frequent occurrences of general anesthesia and surgery. The thoughtful perioperative care of children with Down syndrome is relevant and acutely complex for the pediatric anesthesiologist. Behavior, sedation, hypotonia, upper airway obstruction, venous access, and bradycardia are omnipresent concerns apart from the surgical pathology. Down syndrome is also associated with autonomic nervous system dysfunction, a comorbidity that is overlooked in discussions of perioperative care and is described thus far in adults. Autonomic nervous system function or dysfunction may explain the phenotypical features of the perioperative challenges listed above. For this reason, understanding the development and measurement of autonomic nervous system function is important for the pediatric anesthesiologist. Definition and quantification of sympathetic and parasympathetic function will be reviewed. [ABSTRACT FROM AUTHOR]

Objective: The literature on the entity of the anterior larynx (AL) is restricted to little evidence on the difficulty encountered in exposing the larynx for intubation, perioperative morbidity and mortality, and scant reports on its prevalence in general adults and children. Here, we describe the prevalence of AL in a series of children presenting with aerodigestive symptoms and explore its association with functional abnormalities, congenital and structural anomalies or conditions. Setting: Tertiary paediatric centre. Methods: We conducted a retrospective case–control study. Using a prospectively collected surgical database, we identified patients diagnosed with AL (Grades IIb‐III‐IV Modified Cormack‐Lehane scale) and sex and age‐matched controls who had undergone full airway endoscopy for aerodigestive symptoms. We collected the demographics, presentations, associated diagnoses and investigations. We compared the proportion of patients with large airway abnormalities and dysmorphism and estimated the prevalence of AL. Results: Over a 5.5‐year period, 58 children with AL (28 females, mean age 0.38 years) were matched with 58 controls (mean age 0.42 years). Although both groups presented with permutations of stridor, respiratory failure, cyanotic spells, swallowing and feeding difficulties and SDB, AL presented much more with swallowing and feeding problems (33 vs. 20, p <.05). There were significantly more children with dysmorphism in the AL group (29 vs. 9, p <.05). The prevalence of AL was 4.9% (SE 0.0063). Conclusions: AL was detected in 4.9% of a sample of children who had undergone airway examination for aerodigestive symptoms. It is significantly associated with dysmorphism, and swallowing difficulties that warrant instrumental evaluation. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to determine the incidence of perioperative respiratory complications in children following tonsillectomy with cold and hot dissection surgical techniques. Study Design: The study was a retrospective cohort study. Setting: Retrospective chart review was performed for all children presenting for a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. Methods: Pre- and intraoperative patient factors, including surgical technique with cold or hot dissection (electrocautery or radiofrequency ablation), and perioperative anesthetic factors were collected to determine the incidence of perioperative respiratory complications. Results: A total of 2437 patients underwent a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. The incidence of perioperative respiratory complications was 20.0% (n = 487). Sickle cell disease, cardiac disease, reactive airway disease, pulmonary disease, age >2 and <3 years, and obesity, defined as a body mass index >95th percentile for age, were significant for overall perioperative respiratory complications. There was no difference in the incidence of perioperative respiratory complications in children undergoing tonsillectomy by cold or hot dissection. Conclusion: Perioperative respiratory complications following tonsillectomy are more affected by patient factors than surgical technique. [ABSTRACT FROM AUTHOR]

Perioperative respiratory adverse events pose a significant risk in pediatric anesthesia, and identifying these risks is vital. Traditionally, this is assessed using history and examination. However, the perioperative risk is multifactorial, and children with complex medical backgrounds such as chronic lung disease or obesity may benefit from additional objective preoperative pulmonary function tests. This article summarizes the utility of available pulmonary function assessment tools as preoperative tests in improving post‐anesthetic outcomes. Currently, there is no evidence to support or discourage any pulmonary function assessment as a routine preoperative test for children undergoing anesthesia. In addition, there is uncertainty about which patients with the known or suspected respiratory disease require preoperative pulmonary function tests, what time period prior to surgery these are required, and whether spirometry or more sophisticated tests are indicated. Therefore, the need for any test should be based on information obtained from the history and examination, the child's age, and the complexity of the surgery. [ABSTRACT FROM AUTHOR]

Aim: In children with Prader‐Willi syndrome (PWS), growth hormone (GH) improves height and body composition; however, may be associated with worsening sleep‐disordered breathing (SDB). Some studies have reported less SDB after GH initiation, but follow‐up with polysomnography is still advised in most clinical guidelines. Methods: This retrospective, multicentre study, included children with PWS treated with GH at seven PWS treatment centres in Australia over the last 18 years. A paired analysis comparing polysomnographic measures of central and obstructive SDB in the same child, before and after GH initiation was performed with Wilcoxon signed‐rank test. The proportion of children who developed moderate/severe obstructive sleep apnoea (OSA) was calculated with their binomial confidence intervals. Results: We included 112 patients with available paired data. The median age at start of GH was 1.9 years (range 0.1–13.5 years). Median obstructive apnoea hypopnoea index (AHI) at baseline was 0.43/h (range 0–32.9); 35% had an obstructive AHI above 1.0/h. Follow‐up polysomnography within 2 years after the start of GH was available in 94 children who did not receive OSA treatment. After GH initiation, there was no change in central AHI. The median obstructive AHI did not increase significantly (P = 0.13), but 12 children (13%, CI95% 7–21%) developed moderate/severe OSA, with clinical management implications. Conclusions: Our findings of a worsening of OSA severity in 13% of children with PWS support current advice to perform polysomnography after GH initiation. Early identification of worsening OSA may prevent severe sequelae in a subgroup of children. [ABSTRACT FROM AUTHOR]

Background: The impact of an acute pulmonary exacerbation of cystic fibrosis (CF) on sleep quality has not been established. Patients have greater burden of symptoms, higher intensity of therapy and are often admitted to hospital outside of their usual sleeping environment. Aims: To evaluate the prevalence of, and factors associated with, poor sleep quality in adult patients admitted to hospital with an acute exacerbation of CF lung disease. Methods: This prospective, observational study determined the prevalence of impaired sleep quality and associated factors in adult patients admitted to a single CF unit with an acute pulmonary exacerbation of CF. Sleep quality was defined by the Pittsburgh Sleep Quality Index (PSQI), with >5 indicating poor sleep quality. Data were obtained through patient questionnaires, chart review and examination. Results: Sixty‐six percent of patients had impaired sleep quality. Patients with poor sleep had more sleep disruption due to pain (median response 'mild sleep disruption' vs 'no sleep disruption'; P = 0.003) and insomnia (mean Insomnia Severity Index (ISI) 13 vs 5; P < 0.001). In patients with symptoms of restless legs, poor sleepers had worse symptoms (mean International Restless Legs Severity Score (IRLSS) 15 vs 5; P = 0.029). Univariate modelling showed relationships between PSQI and symptoms of depression and anxiety as well as with sleep disruption due to pain, general noise and nursing observations. In a multivariable model, ISI was the only variable that remained significantly associated with PSQI. Mean PSQI score increased 0.58 units for each 1 unit increase in ISI (95% CI 0.42–0.73; P < 0.001). Conclusions: Poor sleep quality is common among patients admitted with an acute exacerbation of CF and is strongly associated with insomnia symptoms in this cohort. [ABSTRACT FROM AUTHOR]

Aim: Nocturnal enuresis (NE) and sleep‐disordered breathing (SDB) are common in childhood. While the two disorders are linked, those links are still being clarified. Methods: This study compared sleep profiles and enuresis‐related behaviours between children with NE and those without, who were referred to a tertiary sleep unit with suspected SDB, using the combination of polysomnography (PSG) and questionnaire. Continuous numerical data were analysed after adjusting for body mass index z‐score. Results: The study included 52 Children (39 boys, 13 girls) aged 5–14 years. Twenty‐one had enuresis (10 monosymptomatic enuresis (MNE) and 11 non‐monosymptomatic enuresis (NMNE)) and 31 did not have enuresis. The majority had comorbidities. On PSG, all children with NE had moderate obstructive sleep apnoea (OSA) compared to the control group which were of mild OSA. Children with NMNE had a higher percentage time in stage‐3 non‐REM sleep when compared to the non‐enuretic and MNE groups (P < 0.05). On the questionnaire, more parents of the NE groups reported that their child was 'difficult to wake in the morning' (P < 0.05). Conclusion: In this heterogeneous population referred for suspected SDB, children with NE had moderate OSA, yet those with MNE had increased arousals and more often report difficulty waking than children with suspected SDB who do not wet, while children with NMNE exhibit changes in sleep architecture suggesting deeper sleep. These differences may impact treatment choices for children with enuresis. [ABSTRACT FROM AUTHOR]

Background: The polysomnogram (PSG) is the "gold standard" for diagnosing obstructive sleep apnea (OSA). However, nocturnal oximetry is a practical screening tool for children with adenotonsillar hypertrophy (ATH). This study aimed to investigate the incidence of, and predictive factors for, OSA in children with ATH and normal / inconclusive overnight oximetry. Methods: The prospective study enrolled children aged 3–15 years with ATH and normal / inconclusive overnight oximetry. All participants underwent full‐night PSG. To evaluate the predictors of OSA, we used logistic regression analysis, including sex, history of allergic rhinitis, body mass index z‐score, neck circumference–height ratio, and polysomnographic parameters (obstructive apnea–hypopnea index (OAHI), nadir oxygen saturation (SpO2), peak end‐tidal CO2, and arousal index). Results: The participants were 189 children; 167 (88%) were diagnosed with OSA by PSG. A history of allergic rhinitis (P = 0.033), and the PSG findings for nadir SpO2 (P = 0.027) and arousal index (P = <0.001) predicted the diagnosis of OSA. We divided patients with OSA into two groups (mild versus moderate to severe OSA). Patients with OAHI ≥5/h were defined as having moderate‐to‐severe OSA. No clinical factors significantly predicted OAHI ≥5. Of the 189 participants, 58 children (31%) were diagnosed with severe OSA (OAHI ≥10). The only PSG factor that predicted severe OSA was the arousal index (P < 0.001). Conclusions: The observed incidence of OSA in children aged 3–15 years with ATH and normal/inconclusive overnight oximetry was very high. A history of allergic rhinitis may help to triage the patients. The arousal index was a predictor of pediatric OSA. [ABSTRACT FROM AUTHOR]