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This study aimed to create a Czech questionnaire for pediatric obstructive sleep apnea (POSA) risk screening, a first of its kind in the Czech Republic, where options for child polysomnography are limited. Compiling items from established English questionnaires and supplementing them with additional items, we designed the first version of the Czech questionnaire and tested it in a pilot study with parents of 30 children. After pilot feedback, a revised version with dichotomous and 5-item Likert scale questions was tested on 71 children's parents. All children (7-12 years old) underwent a home sleep apnea test to record their apnea-hypopnea index (AHI). The second (40-item) version showed high reliability (93%), with 17 items identified as the most significant. Findings from the final 17-item SEN CZ questionnaire correlated positively with AHI (p < 0.001), demonstrating 84% sensitivity, 86% specificity, and 93% reliability. Three factors, namely breathing problems, inattention, and hyperactivity (characterized by multiple items), were identified to form a higher-order factor of POSA risk, which was further supported by the correlations of their total scores with AHI (p < 0.001). The resulting SEN CZ questionnaire can serve as a tool for POSA risk screening in the Czech Republic without the need to involve medical professionals., (© 2024. The Author(s).)

Objectives: To investigate the vascular networks of the retina and choroid using optical coherence tomography angiography (OCTA) to identify early biomarkers of obstructive sleep apnea (OSA) severity and to evaluate correlations with blood levels of oxidative stress., Study Design: Patients with OSA were diagnosed based on video-polysomnography (PSG) and blood samples were collected to evaluate oxidative stress markers: total antioxidant status (TAS), biological antioxidant potential (BAP) test, Diacron reactive oxygen metabolites (d-ROMs) test. The eyes of children with OSA were evaluated and compared with eyes of healthy age-matched children. OCTA imaging was carried out to evaluate the choroidal and retinal vascular network density indices., Results: A total of 31 children with OSA were recruited and compared with 10 healthy children. Choriocapillaris flow area decreased (p = 0.006) and superficial capillary plexus vessel density increased (p=0.01) with increasing severity of OSA. Children with OSA showed significant differences in TAS and d-ROMs test when compared to normal pediatric values (p<0.05). In calculating the correlations between PSG, oxidative stress, and OCTA variables, there was a negative correlation between choriocapillaris flow area and apnea hypopnea index (AHI) (p = 0.02, r 2 -0.5) and between choriocapillaris flow area and the d-ROMs test (p 0.03; r 2 0.5)., Conclusions: The severity of OSA was associated with the choroidal and retinal capillary vascular networks. The correlation of the choriocapillaris flow area with AHI and the d-ROMs test indicates the connection of the choroidal microvasculature with the number of obstructive apnea and hypopnea events and oxidative stress., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: Local and systemic inflammatory markers and pro-inflammatory cytokines are increased in children with obstructive sleep apnea syndrome (OSAS). Therefore, systemic or topical anti-inflammatory agents are used to treat this syndrome. We evaluated the treatment with systemic corticosteroids in children with severe OSAS and adenotonsillar hypertrophy before surgery., Methods: This was an unblinded open label study. Children with severe OSAS (diagnosed through polysomnography, obstructive apnea-hypopnea index [AHI] > 10 eV/h) were recruited. Exclusion criteria included age < 3 years, history of acute or chronic cardiorespiratory or neuromuscular or metabolic disease; major craniofacial abnormalities; and chromosomal syndromes and epilepsy. Computer-generated random numbers were used for simple randomization of subjects. All children were treated with intranasal beclomethasone spray, and 15 children additionally received oral betamethasone and 0.1 mg/kg per day for 7 days. Sleep clinical record (SCR) and pulsoximetry were performed before and after 7 days in all children., Results: Among 28 children with severe OSAS mean age was 4.5 ± 1.8 years, AHI 20.4 ± 1.8 eV/h). In children treated with intranasal and oral corticosteroids, mean (95.3 ± 1.1 vs 97.0 ± 0.8%, p = 0.0001) and minimum oxygen saturation (78.8 ± 6.3 vs 89.2 ± 4.2, p = 0.001) improved, and the SCR score (12.6 ± 1.2 vs 8.3 ± 1.1, p = 0.0001) was reduced. Children treated only with intranasal beclomethasone spray showed no differences in outcome measures before and after treatments. When we considered the oximetry measures, after corticosteroid treatment, we obtained statistical differences between the 2 groups (p < 0.01)., Conclusions: These results seem to suggest that a short course of oral betamethasone could be useful to treat children with severe OSAS and adenotonsillar hypertrophy waiting for surgery., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Obstructive Sleep Apnoea syndrome (OSAS) is considered a systemic inflammatory disease and is characterized by intermittent hypoxia that can damage the integrity of intestinal barrier and alter gut microbiota composition in adults and animal models. To date there is only one study on snoring children and microbiota but no studies are present on paediatric OSAS related dysbiosis., Study Objectives: To evaluate gut microbiota composition in OSAS children in respect to healthy subjects and investigate the role of sleep parameters in changing gut microbiome., Methods: Sixteen children divided in OSAS and healthy groups. Stool samples were collected from both the two groups to assess gut microbiota composition using 16S rRNA sequencing and a nocturnal pulsossimetry and polysomnography were performed in OSAS children., Results: OSAS children showed a decreased microbial diversity in respect to healthy subjects in terms of number of observed species and Chao1 index (p = 0,01). Firmicutes/Bacteroidetes ratio was directly correlated to Sleep Clinical Record (p = 0,03). The abundance of several inflammation-related strains (Proteobacteria, Clostridiaceae, Oscillospiraceae, Klebsiella) were found significantly modified in relation to sleep parameters. Bacteria implied in the gut barrier integrity (Desulfovibrionaceae, Bacteroides fragilis and Faecalibacterium prausnitzii) were found significantly different in the two study groups and correlated with sleep parameters., Conclusions: OSAS children showed a lower microbiota diversity in respect to heathy subjects and an increase of inflammation and gut barrier disruptors-related strains probably induced by intermittent hypoxia. Further studies should be conducted to understand the role of gut microbiota in OSAS physiopathology and comorbidities in children., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Multiple anatomic and functional risk factors contribute to Obstructive Sleep Apnea (OSA) in children, most of the screening tools only evaluate clinical symptoms. The aim was to describe the evaluation of the short orofacial myofunctional protocol (ShOM) in OSA children, and to analyze if the inclusion of orofacial myofunctional aspects would influence the screening sensitivity/specificity of the Sleep Clinical Record (SCR)., Methods: Children from Brazil and Italy with sleep disordered breathing were evaluated by full night polygraphy, the SCR and the ShOM. For the analysis of the correlations, we normalized the distribution of the children based on the percentiles of the Apnea and Hypopnea Index (AHI). The children were divided in: Group1: first percentile AHI up to25% (cut-off value: AHI≤1.9); Group 2: second percentile from 25% to 75% (cut-off values: 1.9˂AHI≤7.9); Group3: third percentile AHI˃75% (cut = off value: AHI˃7.9). The findings of SCR and ShOM were compared for each group. ROC curve of the sensitivity and specificity of OSA diagnosis were compared for SCR alone and the combined results of SCR plus ShOM., Results: 86 children, 47 girls, 4-11 years, were included, 34 children were obese and 20 overweight. OSA severity and obesity showed a positive correlation (p = 0.04). Mean ShOM score was 5.64 ± 2.27, with a positive correlation to the SCR (p = 0.002). In Group1, the SCR showed more nasal obstruction, arched palate and OSAS score/positive Brouilette questionnaire and the ShOM scored more alterations to breathing mode, breathing type (p = 0.01) and lip competence. In Group 3, we found more tonsillar hypertrophy, Friedman tongue position alteration (p < 0.001), malocclusion and obesity at SCR and more alterations in tongue resting position, tongue deglutition position and malocclusion at ShOM., Conclusions: The myofuntional evaluation contributed to the screening of OSA in children, while alterations of the tongue (resting and deglutition position) were observed in children with the highest AHI percentile. The combination of SCR and ShOM improved the sensitivity and specificity for the identification of pediatric OSA when compared to SCR alone., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: We aimed to detect obstructive sleep apnea (OSA) among school-age children presented with nocturnal enuresis (NE) and to identify the possible risk factors for OSA in them., Methods: Sixty-six children aged > 5-16 years presented with NE were enrolled in the study. Children with urinary tract anatomical abnormalities or infection, intellectual disabilities, genetic syndromes, psychological issues, and diabetes mellitus were excluded. They were clinically examined, scored using sleep clinical record score (SCR), and subjected for full-night polysomnogram (PSG). Children with obstructive apnea/hypopnea index (AHI) ≥ 2 episodes/hour (h) were considered as OSA., Results: Fifty-four children (81.8% of the recruited children) aged 8.3 ± 2.8 years agreed to undergo PSG as 68.5% had OSA with median obstructive AHI of 6.1 (3.7-13.2) episodes/h, median oxygen saturation of 97% and nadir of 88%. Thirty-three percent were obese with significantly higher AHI [7.0 (3.7-12.4) vs. 2.4 (1.3-6.1) episodes/h; p = 0.023]. SCR score correlated significantly with AHI (r 2  = 0.462, p = 0.001) with 91% sensitivity in detecting OSA ≥ 5 episodes/h. Nasal obstruction, adenoid/adult facial phenotype, and arched palate were associated with OSA (p < 0.05)., Conclusion: NE is commonly associated with OSA especially in obese children. Nasal obstruction, abnormal facial phenotype, and high-arched palate were common risk factors.

Study Objectives: In children, the effect of the common phenotype of obstructive sleep apnea (OSA) on sleep architecture is not adequately documented. The aim of this study was to evaluate sleep architecture in a pediatric population with the common phenotype of OSA., Methods: The prospective cross-sectional study included 116 children in the age range of 3 to 8 years with suspected OSA and 51 healthy children. All children underwent standard overnight in-laboratory video polysomnography. Patients with obstructive apnea-hypopnea index ≥ 1, adenotonsillar hypertrophy, a long face, narrow palate or minor malocclusions, and no obesity were defined as a common phenotype. Polysomnographic parameters of sleep architecture and sleep clinical record were statistically analyzed according to OSA and its severity., Results: In total, 94 pediatric patients (59.60% male) received the diagnosis of the common phenotype of OSA (mean age of 5.25 ± 1.39 years). A lower percentage of stage N3 sleep (27.70 ± 3.76% versus 31.02 ± 4.23%; P < .05), a greater percentage of stage N1 sleep (8.40 ± 3.98% versus 2.68 ± 3.02%, P < .01), reduced deep sleep efficiency (46.01 ± 4.98% versus 50.25 ± 3.72%; P < .05) and longer sleep latency (18.40 ± 8.48 minutes versus 9.90 ± 11.55 minutes, P < .01) were found in children with the common phenotype of OSA compared with healthy controls. No significant differences were found in total sleep time, sleep efficiency, and percentage of stage R sleep and stage N2 sleep between groups and in sleep stage distribution and cyclization., Conclusions: These findings suggest that the most common phenotype of pediatric OSA has a negative effect on the structure of sleep, but other clinical studies are needed to confirm this result., (© 2018 American Academy of Sleep Medicine)

The present statement was produced by a European Respiratory Society Task Force to summarise the evidence and current practice on the diagnosis and management of obstructive sleep disordered breathing (SDB) in children aged 1-23 months. A systematic literature search was completed and 159 articles were summarised to answer clinically relevant questions. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are identified. Morbidity (pulmonary hypertension, growth delay, behavioural problems) and coexisting conditions (feeding difficulties, recurrent otitis media) may be present. SDB severity is measured objectively, preferably by polysomnography, or alternatively polygraphy or nocturnal oximetry. Children with apparent upper airway obstruction during wakefulness, those with abnormal sleep study in combination with SDB symptoms ( e.g. snoring) and/or conditions predisposing to SDB ( e.g. mandibular hypoplasia) as well as children with SDB and complex conditions ( e.g. Down syndrome, Prader-Willi syndrome) will benefit from treatment. Adenotonsillectomy and continuous positive airway pressure are the most frequently used treatment measures along with interventions targeting specific conditions ( e.g. supraglottoplasty for laryngomalacia or nasopharyngeal airway for mandibular hypoplasia). Hence, obstructive SDB in children aged 1-23 months is a multifactorial disorder that requires objective assessment and treatment of all underlying abnormalities that contribute to upper airway obstruction during sleep., Competing Interests: Conflict of interest: None declared., (Copyright ©ERS 2017.)

Purpose: Data in the literature suggest that myofunctional therapy (MT) may be able to play a role in the treatment of children with sleep-disordered breathing (SDB). Our study investigated the effectiveness of MT in reducing respiratory symptoms in children with SDB by modifying tongue tone., Methods: Polysomnographic recordings were performed at baseline to assess obstructive sleep apnea (OSA) severity in 54 children (mean age 7.1 ± 2.5 years, 29 male) with SDB. Patients were randomly assigned to either the MT or no-MT group. Myofunctional evaluation tests, an assessment of tongue strength, tongue peak pressure, and endurance using the Iowa Oral Performance Instrument (IOPI), and nocturnal pulse oximetry were performed before (T0) and after (T1) 2 months of treatment., Results: MT reduced oral breathing (83.3 vs 16.6%, p < 0.0002) and lip hypotonia (78 vs 33.3%, p < 0.003), restored normal tongue resting position (5.6 vs 33.4%, p < 0.04), and significantly increased mean tongue strength (31.9 ± 10.8 vs 38.8 ± 8.3, p = 0.000), tongue peak pressure (34.2 ± 10.2 vs 38.1 ± 7.0, p = 0.000), and endurance (28.1 ± 8.9 vs 33.1 ± 8.7, p = 0.01) in children with SDB. Moreover, mean oxygen saturation increased (96.4 ± 0.6 vs 97.4 ± 0.7, p = 0.000) and the oxygen desaturation index decreased (5.9 ± 2.3 vs 3.6 ± 1.8, p = 0.001) after MT., Conclusions: Oropharyngeal exercises appear to effectively modify tongue tone, reduce SDB symptoms and oral breathing, and increase oxygen saturation, and may thus play a role in the treatment of SDB.

Purpose: The aim of our study was to evaluate the utility of the sleep clinical record (SCR) in the follow-up of children with obstructive sleep apnea (OSA) after treatment., Methods: SCR was completed and overnight polysomnography (PSG) was performed in all enrolled children (T0), with SCR considered positive for scores ≥6.5, as previously validated. Patients underwent adenotonsillectomy (T&A), rapid maxillary expansion (RME), and medical therapy according to severity of OSA and clinical features. Six months after completing therapy, the second overnight PSG and SCR (T1) were performed., Results: For all subjects, both Apnea-Hypopnea Index (AHI) and total SCR score decreased significantly (<0.005) from T0 to T1. For SCR items, clinical examination (item 1) and reported sleep respiratory symptoms (item 2) ameliorated significantly (<0.005). However, hyperactivity or inattention (item 3) decreased significantly (<0.005) after treatment only in T&A group, while no differences in AHI and SCR scores occurred in the medically treated group. At T1, SCR was positive in 95.6 % of children with AHI ≥1, with a concordance of 100 % in the T&A and RME groups, resulting in a positive predictive value of 100 %. A poor concordance (38.3 % in T&A group and 53.4 % in RME group) was found when SCR < 6.5. Children with SCR ≥ 6.5 at T1 showed higher AHI compared to patients with SCR < 6.5 (5.7 ± 5.9 ev/h vs 1.78 ± 1.76 ev/h; p < 0.005)., Conclusions: SCR emerges as a potentially useful instrument for follow-up of children with OSA after treatment.

This document summarises the conclusions of a European Respiratory Society Task Force on the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and refers to children aged 2-18 years. Prospective cohort studies describing the natural history of SDB or randomised, double-blind, placebo-controlled trials regarding its management are scarce. Selected evidence (362 articles) can be consolidated into seven management steps. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are present (step 1). Central nervous or cardiovascular system morbidity, growth failure or enuresis and predictors of SDB persistence in the long-term are recognised (steps 2 and 3), and SDB severity is determined objectively preferably using polysomnography (step 4). Children with an apnoea-hypopnoea index (AHI) >5 episodes·h(-1), those with an AHI of 1-5 episodes·h(-1) and the presence of morbidity or factors predicting SDB persistence, and children with complex conditions (e.g. Down syndrome and Prader-Willi syndrome) all appear to benefit from treatment (step 5). Treatment interventions are usually implemented in a stepwise fashion addressing all abnormalities that predispose to SDB (step 6) with re-evaluation after each intervention to detect residual disease and to determine the need for additional treatment (step 7)., (Copyright ©ERS 2016.)

Objectives: To investigate the activity of the autonomic nervous system (ANS) during sleep in children with obstructive sleep apnea (OSA), in order to detect a possible cardiac ANS imbalance analyzing heart rate variability (HRV)., Methods: 43 subjects between 4 and 12 years of age (7.26 ± 2.8 years), undergoing a diagnostic assessment for OSA were evaluated. A time domain index (R-apnea index) was developed to evaluate HRV strictly related to obstructive events during sleep. Poincaré plot of RR intervals during the whole night was calculated., Results: R-apnea index was negatively correlated with apnea hypopnea index (AHI) (r=-0.360, p=0.028). AHI and the duration of the disease were the only variables that were significantly correlated with R-apnea index. Three groups were subsequently created according to polysomnographic findings considering AHI. R-apnea index resulted significantly lower in patient with severe OSA compared to primary snoring/mild OSA subjects (p<0.05). Looking at Poincaré plot, SD1 showed a diminishing trend with severity of OSA, however not reaching statistical significance., Conclusions: Our findings suggest an autonomic impairment in OSA children evidenced by the altered HRV both in the very short term (R-apnea index) and in short term (SD1)., Significance: R-apnea index is an easy and cheap method to undelay early ANS imbalance., (Copyright © 2015 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

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

Importance: Although polysomnographic (PSG) testing is the gold standard for the diagnosis of obstructive sleep apnea syndrome (OSAS) in children, the number of pediatric sleep laboratories is limited. Developing new screening methods for identifying OSAS may reduce the need for PSG testing., Objective: To evaluate the combined use of the sleep clinical record (SCR) and nocturnal oximetry testing for predicting PSG results in children with clinically suspected OSAS., Design, Setting, and Participants: Prospective study over 10 months. A cohort of 268 consecutive children (mean [SD], age 6 [3] years) referred for clinically suspected OSAS was studied at a pediatric sleep center at a university hospital. Children with disorders other than adenotonsillar hypertrophy or obesity were excluded., Main Outcomes and Measures: Mild OSAS (obstructive apnea-hypopnea index [AHI], 1-5 episodes/h) and moderate-to-severe OSAS (AHI, >5 episodes/h) were the main outcome measures. Sleep clinical record scores greater than or equal to6.5 were considered positive, as were McGill oximetry scores (MOS) greater than 1, and these positive scores were the main explanatory variables in our study. Each participant was evaluated by the SCR, followed by pulse oximetry test the first night and PSG test in the sleep laboratory the second night., Results: Of the total participants, 236 (88.1%) were diagnosed with OSAS, 236 (88.1%) had a positive SCR score, and 50 (18.7%) had a positive MOS. Participants with positive SCR scores had significantly increased risk of an AHI greater than or equal to 1 (adjusted odds ratio [AOR], 9.3; 95% CI, 3.7-23.2; P < .001). Children with an MOS greater than 1 were significantly more likely to have an AHI greater than 5 episodes/h than children with an MOS equal to 1 (AOR, 26.5; 95% CI, 7.8-89.2; P < .001). A positive SCR score had satisfactory sensitivity (91.9%) and positive predictive value (91.9%) but limited specificity (40.6%) and negative predictive value (40.6%) for OSAS. An MOS greater than 1 had excellent specificity (97.4%) and positive predictive value (94%) but low sensitivity (39.2%) and fair negative predictive value (60.8%) for moderate-to-severe OSAS among children with a positive SCR score. The combination of SCR scores and MOS correctly predicted primary snoring, mild OSAS, or moderate-to-severe OSAS in 154 of 268 (57.4%) participants., Conclusions and Relevance: The combined use of the SCR score and nocturnal oximetry results has moderate success in predicting sleep-disordered breathing severity when PSG testing is not an option.

Objectives: The objectives of this study were to confirm the efficacy of rapid maxillary expansion in children with moderate adenotonsillar hypertrophy in a larger sample and to evaluate retrospectively its long-term benefits in a group of children who underwent orthodontic treatment 10 years ago., Methods: After general clinical examination and overnight polysomnography, all eligible children underwent cephalometric evaluation and started 12 months of therapy with rapid maxillary expansion. A new polysomnography was performed at the end of treatment (T1). Fourteen children underwent clinical evaluation and Brouilette questionnaire, 10 years after the end of treatment (T2)., Results: Forty patients were eligible for recruitment. At T1, 34/40 (85%) patients showed a decrease of apnea-hypopnea index (AHI) greater than 20% (ΔAHI 67.45% ± 25.73%) and were defined responders. Only 6/40 (15%) showed a decrease <20% of AHI at T1 and were defined as non-responders (ΔAHI -53.47% ± 61.57%). Moreover, 57.5% of patients presented residual OSA (AHI > 1 ev/h) after treatment. Disease duration was significantly lower (2.5 ± 1.4 years vs 4.8 ± 1.9 years, p <0.005) and age at disease onset was higher in responder patients compared to non-responders (3.8 ± 1.5 years vs 2.3 ± 1.9 years, p <0.05). Cephalometric variables showed an increase of cranial base angle in non-responder patients (p <0.05). Fourteen children (mean age 17.0 ± 1.9 years) who ended orthodontic treatment 10 years previously showed improvement of Brouilette score., Conclusion: Starting an orthodontic treatment as early as symptoms appear is important in order to increase the efficacy of treatment. An integrated therapy is needed., (Copyright © 2014 Elsevier B.V. All rights reserved.)

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

Background: F2-isoprostanes are considered to be a reliable standard biomarker of oxidative stress in vivo because they are not influenced by the intake of lipids in the diet, and they are chemically stable molecules and easily detected. This study aimed to test the hypothesis that 8-isoprostane level is a useful marker to valuate the severity of pediatric obstructive sleep apnea (OSA)., Methods: Sixty-five children with sleep-disordered breathing (SDB) (mean age 5.9±2.0 years; 63.1% males) were recruited. The urine sample for the measurement of 8-isoprostane was collected the morning after the polysomnographic recording. Children were divided into two groups according to their apnea-hypopnea index (AHI)., Results: Urinary 8-isoprostane levels positively correlated with the sleep clinical record score (r=0.38, p=0.002) and AHI (r=0.24, p=0.05) and negatively correlated with age (r=-0.36, p=0.003) and body surface area (r=-0.38, p=0.002). Urinary 8-isoprostane levels were significantly higher in the group with AHI of ≥5 events (ev)/h than in the group with AHI of <5 ev/h (p<0.01)., Conclusions: Urinary 8-isoprostane may be used as a specific inflammatory marker to predict the severity of OSA; this method has the advantage of being noninvasive and easy to use in both compliant and noncompliant children.

Purpose: Rapid maxillary expansion (RME) is an additional treatment in pediatric obstructive sleep apnea (OSA). The aim of this study was to present data about the outcome of adenotonsillectomy (AT) and of RME in a clinical sample of pediatric OSA., Methods: We consecutively enrolled children with OSA to undergo RME or AT. The age and the severity of OSA are the main factors involved in the choice of treatment. A polysomnography was performed at the baseline (i.e., before treatment, T0) and 1 year after treatment (T1)., Results: A total of 52 subjects fulfilled the inclusion criteria. Twenty-five children underwent AT (group 1) and 22 children underwent RME (group 2). Five children underwent both treatments (group 3). Children in group 2 were older, had a longer disease duration, a higher body mass index (BMI), a lower apnea-hypopnea index (AHI), and a lower arousal index at T0 than children in group 1. After 1 year, BMI percentile and overnight mean saturation increased in group 1 while AHI and arousal index decreased. In group 2, mean overnight saturation increased while AHI decreased. Children in group 3 displayed a significant decrease in AHI from T0 to T1., Conclusions: Our data demonstrate that both treatments help to improve OSA, and a multidisciplinary approach to treatment is suggested.

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

Overnight polysomnography (PSG) is an expensive procedure which can only be used in a minority of cases, although it remains the gold standard for the diagnosis of sleep disordered breathing (SDB). The objective of this study was to develop a simple, PSG-validated tool to screen SDB, thus reducing the use of PSG. For every participant we performed PSG and a sleep clinical record was completed. The sleep clinical record consists of three items: physical examination, subjective symptoms and clinical history. The clinical history analyses behavioural and cognitive problems. All three items were used to create a sleep clinical score (SCS). We studied 279 children, mean ± SD age 6.1 ± 3.1 years, 63.8% male; 27.2% with primary snoring and 72.8% with obstructive sleep apnoea (OSA) syndrome. The SCS was higher in the OSA syndrome group compared to the primary snoring group (8.1 ± 9.6 versus 0.4 ± 0.3, p<0.005), correlated with apnoea/hypopnoea index (p=0.001) and had a sensitivity of 96.05%. Positive and negative likelihood ratios were 2.91 and 0.06, respectively. SCS may effectively be used to screen patients as candidates for PSG study for suspected OSA syndrome, and to enable those with a mild form of SDB to receive early treatment.

Background: Orthodontic and craniofacial abnormalities have often been reported in pediatric sleep-disordered breathing (SDB). While the reversibility of these craniofacial abnormalities by means of adenotonsillectomy has yet to be established, orthodontic treatment based on oral appliances is considered to be a potential additional treatment for pediatric SDB., Discussion: Oral appliances may help improve upper airway patency during sleep by enlarging the upper airway and/or by decreasing upper airway collapsibility, thereby enhancing upper airway muscle tone. Orthodontic therapy should be encouraged in pediatric OSAS, and an early approach may permanently modify nasal breathing and respiration, thereby preventing obstruction of the upper airway.

Background: This study aims to evaluate left ventricular (LV) structure and function and inflammation in a paediatric population with sleep disordered breathing (SDB) and in control subjects., Methods: Forty-nine children with SDB and 21 healthy, age-matched subjects were enrolled. The diagnosis of obstructive sleep apnoea syndrome (OSAS) was confirmed by the laboratory polysomnography, showing an obstructive apnoea/hypopnoea index of more than one per hour, according to the criteria of the American Academy of Sleep Medicine and modified for paediatric population. Fasting blood samples for the biochemical evaluation (including high-sensitivity C-reactive protein (hsCRP) were drawn in the morning, after the polysomnographic examination in all patients with SDB and in the control group. All children underwent a two-dimensional colour Doppler cardiac examination with LV mass assessment and systolic and diastolic function evaluation., Results: Higher hsCRP levels were observed in subjects with OSAS than in children with primary snoring and in controls (0.8 ± 0.7 vs 0.3 ± 0.1 ng/dl, p = 0.001, and 0.4 ± 0.2 ng/dl, p = 0.01, respectively). The LV diastolic dysfunction was significantly more frequent in patients with severe OSAS and higher hsCRP levels than in control group., Conclusions: This study shows that OSAS in children is associated with higher LV mass, early LV diastolic dysfunction and a pro-inflammatory state (high CRP levels). These findings might help to explain the higher incidence of cardiovascular morbidity in patients with OSAS.

Purpose: In view of the positive outcome of orthodontic treatment using rapid maxillary expansion (RME) on sleep-disordered breathing, we generated data on RME in children with obstructive sleep apnea (OSA) by evaluating objective and subjective data over a 36-month follow-up period, to determine whether RME is effective in the long-term treatment of OSA. We selected all patients with dental malocclusions and OSA syndrome (OSAS) confirmed by polysomnography., Methods: Ten of the 14 children who completed the 12-month therapeutic trial using RME were enrolled in our follow-up study. The study was performed 24 months after the end of the RME orthodontic treatment. We enrolled all children presented with deep, retrusive or crossbite at the orthodontic evaluation. All subjects underwent an overnight polysomnography at the baseline, after 1 year of treatment and 24 months after the end of the orthodontic treatment. The children's mean age was 6.6 ± 2.1 years at entry and 9.7 ± 1.6 years at the end of follow-up., Results: After treatment, the apnea hypopnoea index (AHI) decreased and the clinical symptoms had resolved by the end of the treatment period. Twenty-four months after the end of the treatment, no significant changes in the AHI or in other variables were observed., Conclusions: RME may be a useful approach in children with malocclusion and OSAS, as the effects of such treatment were found to persist 24 months after the end of treatment.

Study Objectives: The aim of our study was to investigate cardiovascular autonomic activity during wakefulness, using cardiovascular tests, in a population of children with OSAS., Design: Prospective study., Setting: Sleep unit of an academic center., Participants: We included 25 children (mean age 10.2 +/- 2.3 years) undergoing a diagnostic assessment for OSAS, and 25 age-matched healthy control subjects. All subjects underwent an overnight polysomnography and autonomic cardiovascular tests using parts of the Ewing test battery, which is a physiological test used for the assessment of autonomic function (head-up tilt test, Valsalva maneuver, deep breathing test)., Measurements and Results: Eighteen of 25 children with OSAS (11 males, mean age 9.4 +/- 1.7 years) concluded the study. OSAS patients had higher systolic blood pressure, diastolic blood pressure, baseline heart rate, the 30:15 index (which represents the RR interval at the 15th and 30th beats during the head up tilt test), and delta diastolic and systolic blood pressure during the head-up tilt test, while the heart rate variability during the deep breathing test was lower, compared with controls. A positive correlation between systolic and diastolic blood pressure and the apnea-hypopnea index (AHI), and negative between AHI and both the 30:15 index and Valsalva ratio, were found. Stepwise linear regression analysis detected a negative correlation between AHI and the 30:15 index and Valsalva ratio, a positive correlation between overnight mean oxygen saturation and delta heart rate, and between AHI and delta systolic blood pressure., Conclusions: Our data point to an increase in basal sympathetic activity during wakefulness and to an impaired reaction to several physiological stimuli, which is dependent on the severity of OSAS.

Objective: To compare the new American Academy of Sleep Medicine (AASM) criteria for scoring sleep with the previous Rechtschaffen and Kales (R&K) criteria in a cohort of children with primary snoring, obstructive sleep apnea syndrome (OSAS) and normal controls., Methods: Polysomnography was performed in 26 consecutive children with primary snoring (13 males, mean age 6.2 years, SD 3.2), in 39 with OSAS (24 males, mean age 6.1 years, SD 3.0), and in 10 age-matched normal controls., Results: Compared to the other groups, OSAS children showed a lower percentage of slow-wave sleep, using both R&K and AASM criteria; they also showed a higher percentage of stage shifts, and N1, using the AASM criteria. Children with primary snoring showed a higher percentage of N1, compared to controls., Conclusions: These results indicate that the use of the new AASM criteria seem to disclose more differences in sleep parameters than the R&K rules in children with OSAS., Significance: The AASM criteria seem to disclose a high degree of sleep fragmentation in children with OSAS, mostly related to the repeated occurrence of N1., (Copyright 2009 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate NREM sleep microstructure in children with obstructive sleep apnea syndrome (OSAS) before and after one year of rapid maxillary expander (RME) treatment by means of the cyclic alternating pattern (CAP)., Methods: Nine children with OSAS aged 4-8 years (6 males, mean age 6.4+/-1.97 years) and age-matched normal controls were included. All subjects underwent an overnight polysomnography in the sleep laboratory after one adaptation night, as a baseline evaluation; children with OSAS were recorded again after one year of RME treatment., Results: After one year of treatment the OSAS group showed a longer duration of time in bed and sleep period time, a reduction in number of stage shifts compared to baseline recordings, and the apnea-hypopnea index decreased significantly. At baseline, the OSAS group had a higher CAP rate during slow-wave sleep and an increased A2 index compared to normal controls. After one year of RME application, children with OSAS showed an increase in CAP rate associated with an increase of A1 index during slow-wave sleep., Conclusions: RME treatment almost normalized sleep architecture and improved sleep respiratory disturbances; however, sleep microstructure and respiratory parameters did not completely recover. The persistence of increased CAP rate in slow-wave sleep associated with an increase of A1 index might reflect a partial failure of orthodontic treatment. On the other hand, the rebound of A1 subtypes might be an indirect sign of an attempt to normalize sleep that has been disturbed by the respiratory events.

Study Objectives: Sleep breathing disorders may trigger paroxysmal events during sleep such as parasomnias and may exacerbate preexisting seizures. We verified the hypothesis that the amount of EEG paroxysmal activity (PA) may be high in children with obstructive sleep apnea syndrome (OSAS)., Design: Prospective study., Settings: Sleep unit of an academic center., Participants: Polysomnographic studies were performed in a population of children recruited prospectively, for suspected OSAS, from January to December 2007, with no previous history of epileptic seizures or any other medical conditions. All sleep studies included > or = 8 EEG channels, including centrotemporal leads. We collected data about clinical and respiratory parameters of children with OSAS and with primary snoring, then we performed sleep microstructure analysis in 2 OSAS subgroups, matched for age and sex, with and without paroxysmal activity., Measurements and Results: We found 40 children who met the criteria for primary snoring, none of them showed PA, while 127 children met the criteria for OSAS and 18 of them (14.2%) showed PA. Children with PA were older, had a predominance of boys, a longer duration of OSAS, and a lower percentage of adenotonsillar hypertrophy than children without PA. Moreover, PA occurred over the centrotemporal regions in 9 cases, over temporal-occipital regions in 5, and over frontocentral regions in 4. Children with PA showed a lower percentage of REM sleep, a lower CAP rate and lower A1 index during slow wave sleep, and lower total A2 and arousal index than children without EEG abnormalities., Conclusions: We found a higher percentage of paroxysmal activity in children with OSAS, compared to children with primary snoring, who did not exhibit EEG abnormalities. The children with paroxysmal activity have peculiar clinical and sleep microstructure characteristics that may have implications in the neurocognitive outcome of OSAS.

We describe an obese child with severe obstructive sleep apnea syndrome in whom nocturnal frontal lobe seizures developed within a week after therapy was started with continuous positive airway pressure. The video polysomnographic study after the onset of nocturnal episodes showed 3 seizures: 2 starting from slow-wave sleep when he was sleeping with continuous positive airway pressure, and 1 from stage 2 non-rapid eye movement sleep when he was sleeping without continuous positive airway pressure. Cyclic alternating pattern analysis during the video polysomnography recorded after the onset of nocturnal seizures disclosed a high cyclic alternating pattern rate during slow-wave sleep, and the recording obtained after antiepileptic therapy began showed a low cyclic pattern analysis rate. In this child, we describe the non-rapid eye movement sleep instability induced by continuous positive airway pressure therapy might have had a role in triggering the nocturnal seizures.

Study Objectives: To evaluate NREM sleep instability, as measured by the cyclic alternating pattern (CAP), in a cohort of children with mild sleep disordered breathing (SDB) or frank obstructive sleep apnea (OSA) and normal controls., Design: Prospective study., Settings: Sleep laboratory in academic center., Participants: Twenty-two patients (13 boys; mean age 6.5 +/- 2.4 years; 10 with mild SDB and 12 with OSA) and 15 normal children matched for age underwent overnight polysomnographic recordings in a standard laboratory setting. Sleep was visually scored for sleep macrostructure and CAP in a blinded fashion using standard criteria. Markovian analysis was also performed., Measurements and Results: Participants with OSA had reduced total CAP rates than normal controls and mild SDB patients. Children with mild SDB or OSA had a lower number of A1, lower A1 percentage, and lower A1 index than controls. Children with OSA also showed longer intervals between consecutive A phases and a decrease in entropy in the Markovian analysis., Conclusions: The lower CAP rate and its reduced entropy in children with mild SDB or OSA seem to indicate the presence of subtle sleep alterations that are not clearly identifiable with other approaches and might provide more robust correlates of neurocognitive and behavioral dysfunction in snoring children.

Objectives: To assess the outcome of rapid maxillary expansion in the treatment of obstructive sleep apnea syndrome (OSAS) in children, we studied 16 patients (mean age 6.6+/-2.0; 9 males) with dental malocclusion, a body mass index < or =85 percentile, and OSAS confirmed by polysomnography., Methods: At baseline and after the trial, all patients underwent physical examination, standard polysomnography and orthodontic assessment. The Brouillette questionnaire investigating symptoms of OSA was administered to parents before and during the trial to assess the clinical severity of their sleep-disordered breathing. Two treated patients were lost to follow-up and excluded from the final study., Results: In the 14 treated subjects who completed the study and follow-up, polysomnography showed a significant decrease in the apnea-hypopnea index (p=0.005), hypopnea obstructive index (p=0.002) and arousal index (p=0.001). Questionnaire responses before and after treatment showed a significant decrease in the severity of symptoms., Conclusion: A rapid maxillary expander is an effective appliance for treating children with OSAS.