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To determine if pediatric obstructive sleep apnea syndrome (OSAS) caused by adenotonsillar hypertrophy (ATH) could be treated by a short course of systemic corticosteroids, we conducted an open-label pilot study in which standardized assessments of symptomatology, OSAS severity, and adenotonsillar size were performed before and after a 5-day course of oral prednisone, 1.1+/-0.1 (+/-SE) mg/kg per day. Outcome measures included symptom severity, adenotonsillar size, and polysomnographic measures of OSAS. Selection criteria included age from 1 to 12 years, ATH, symptomatology suggesting OSAS, an apnea/hypopnea index (AHI) > or = 3/hour, and intent to perform adenotonsillectomy. Only one of nine children showed enough improvement to avoid adenotonsillectomy. Symptomatology did not improve after corticosteroid treatment but did after removal of tonsils and adenoids. Polysomnographic indices of OSAS severity did not improve after corticosteroid treatment. After corticosteroids, tonsillar size decreased in only two patients, adenoidal size was only marginally reduced, and the size of the nasopharyngeal airway was not significantly increased. These results suggest that a short course of prednisone is ineffective in treating pediatric OSAS caused by ATH. [ABSTRACT FROM AUTHOR]

Background: Obstructive sleep apnea (OSA) is a risk factor for cardiovascular disease, metabolic disorders, and cognitive dysfunction. Current thinking links chronic intermittent hypoxia (CIH) with oxidative stress and systemic inflammation. However, the sequence of events leading to the morbidities associated with OSA is poorly understood in children. Monocytes are known to be altered by chronic hypoxia. Thus in this prospective study, we investigated inflammatory cytokine profiles from cultures of peripheral blood mononuclear cells (PBMC) obtained from children with severe OSA and sleep-related CIH., Methods: Ten children with OSA (cases) and 5 age-matched children without OSA (controls) were recruited for study. Samples of plasma and PBMC were obtained before and after adenotonsillectomy. The levels of the inflammatory cytokines, interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor-α (TNFα), were measured in both plasma and ex vivo culture supernatants of PBMC incubated with lipopolysaccharide (LPS) using the cytometric bead assay., Results: Upon activation of PBMC by LPS, the levels of IL-8 in the culture supernatants from cases were threefold higher than in controls. The levels of the other cytokines including IL-1β, IL-6, and TNFα, in culture supernatant of PBMC from cases showed no difference from controls; nor were there significant differences in plasma cytokine levels., Conclusion: We speculate that in young children with sleep-related CIH, an enhanced production capacity of IL-8 precedes the development of systemic inflammatory markers. Future work should evaluate IL-8 production capacity as a potential biomarker for OSA severity., Competing Interests: The authors declare that they have no competing interests.

Background: Sleep disorders are prevalent in children and are associated with significant comorbidity., Objective: To assess the training, knowledge, attitudes and practices of Canadian health care providers (HCPs) regarding sleep disorders in children., Method: A 42-item survey, designed to collect information on frequency of paediatric sleep disorders-related screening and diagnosis, implementation of evidence-based interventions and related knowledge base, was completed by HCPs., Results: Ninety-seven HCPs completed the survey. One per cent obtained training in paediatric sleep during undergraduate training and 3% obtained such training during their residencies, yet 34.9% estimated that 25 to 50% of their patients suffered from sleep disorders. Most HCPs thought that sleep disorders significantly impacted children's health and daytime function. Most HCPs screened for developmental sleep issues, but not consistently for sleep disorders. Most recommended evidence-based behavioural interventions for behavioural sleep disorders, but some also reported behavioural interventions that were not first-line or recommended. Inadequate knowledge regarding melatonin use was evident. Most participants reported rarely/never ordering a sleep study for a child with suspected obstructive sleep apnea (OSA). Most were familiar with surgical and weight loss management options for OSA; many were unfamiliar with benefits of continuous positive airway pressure. Participants' knowledge scores were highest on developmental and behavioural aspects of sleep, and lowest on sleep disorders., Conclusions: HCPs exhibit significant gaps in their knowledge, screening, evaluation and treatment practices for paediatric sleep disorders. Training at the undergraduate, graduate and postgraduate levels, as well as Continuing Medical Education are needed to optimize recognition, treatment and follow-up of paediatric sleep disorders.

Importance: Evaluation of pediatric obstructive sleep apnea in resource-limited health care systems necessitates testing modalities that are accurate and more cost-effective than polysomnography., Objective: To trace the clinical pathway of children referred to our sleep laboratory for possible obstructive sleep apnea who were evaluated using nocturnal pulse oximetry and the McGill Oximetry Score., Design, Setting, and Participants: This was a retrospective cohort study of children 2 to 17 years old with suspected obstructive sleep apnea due to adenotonsillar hypertrophy, conducted at a Canadian pediatric tertiary care center., Interventions: Nocturnal pulse oximetry studies scored using the McGill Oximetry Score., Main Outcomes and Measures: For children who underwent adenotonsillectomy we determined the length of time from oximetry to surgery, postoperative length of stay, postoperative readmissions, and emergency department visits in the month following surgery and major surgical complications. We analyzed these outcomes by oximetry result. We compared the cost savings of our diagnostic approach with those of other diagnostic models., Results: Among 362 children, the median age was 4.8 years (interquartile range, 3.3-6.7), and 61% were male. Two-hundred-sixty-six (73%) and 96 (27%), respectively, had inconclusive and abnormal oximetry results. Eighty of 96 of children with abnormal oximetry results (83%) and 81 of 266 children with inconclusive oximetry results (30%) underwent adenotonsillectomy. Thirty-three of 266 children (12%) underwent further evaluation with polysomnography; of 14 diagnosed as having OSA, 12 underwent adenotonsillectomy. Children with abnormal oximetry results were operated on soonest after testing and triaged based on oximetry results. No child with an inconclusive oximetry result required hospitalization for more than 1 night postoperatively; 14% of children (11 of 80) with an abnormal oximetry result required hospitalization for 2 or 3 nights (χ2 = 12.0; P = .001). Rates of readmissions and emergency department visits were low, irrespective of oximetry results (whether inconclusive or abnormal). We show that our oximetry-based diagnostic approach results in considerable cost savings compared with a polysomnography-for-all approach., Conclusions and Relevance: Oximetry studies evaluated with the McGill Oximetry Score expedite diagnosis and treatment of children with adenotonsillar hypertrophy referred for suspected sleep-disordered breathing. When resources for testing for sleep-disordered breathing are rationed or severely limited, our proposed diagnostic approach can help maximize cost-savings and allows sleep laboratories to focus resources on medically complex children requiring polysomnographic evaluation of suspected sleep disorders.

Rationale: At-home nocturnal pulse oximetry has a high positive predictive value (PPV) for polysomnographically-diagnosed obstructive sleep apnea (OSA) but no studies have been published testing the night-to-night consistency of at-home nocturnal pulse oximetry for the evaluation of suspected OSA in children. We therefore determined the night-to-night consistency of nocturnal pulse oximetry as a diagnostic test for OSA in children., Methods: We prospectively studied 148 children (96 male) aged 4.9 ± 2.4 (1.2-11.8) years, referred for suspected OSA. To evaluate night-to-night consistency, we compared an oximetry analysis method, the McGill Oximetry Score (MOS), from two consecutive at-home nocturnal pulse oximetry recordings., Results: Pulse oximetry metrics were similar on the two nights. The MOS on the two nights showed excellent night-to-night consistency when analyzed as positive for OSA versus inconclusive, 143/148 (Spearman's correlation coefficient = 0.90). A more detailed analysis using four categories (MOS 1, 2, 3, and 4) of OSA severity showed very good night-to-night agreement, 133/148 (Spearman's correlation coefficient = 0.91). Variability was increased in children younger than 4 years of age compared to older children., Conclusions: Night-to-night consistency of nocturnal pulse oximetry as a diagnostic test for OSA showed excellent agreement. Night-to-night consistency of pulse oximetry, as analyzed by the MOS, for diagnosis and severity evaluation further validates this abbreviated testing method for pediatric OSA. Polysomnography (PSG) is required to rule in or rule out OSA in children if a single night oximetry testing is inconclusive., (Copyright © 2013 Wiley Periodicals, Inc.)

Children with neurodevelopmental disabilities, such as cerebral palsy, are considered to be a population at risk for the occurrence of sleep problems. Moreover, recent studies on children with cerebral palsy seem to indicate that this population is at higher risk for sleep disorders. The importance of the recognition and treatment of sleep problems in children with cerebral palsy cannot be overemphasized. It is well known that the consequences of sleep disorders in children are broad and affect both the child and family. This review article explores the types and possible risk factors associated with the development of sleep problems in children with cerebral palsy and the impact of this disorder on the child and family. In addition, a brief summary of current diagnostic and treatment modalities is provided. Finally, the characteristics, diagnostic techniques, and management of sleep-related breathing disorders in children with cerebral palsy are discussed.

Objective: To determine whether neighborhood characteristics or socioeconomic status are risk factors for obstructive sleep apnea (OSA) in young children., Study Design: In this observational study, we compared residential census tract metrics in Montreal, Canada for 436 children aged 2-8 years who were evaluated for OSA, hypothesizing that the children with proven OSA (OSA group; n = 300) would come from more disadvantaged neighborhoods compared with those children without OSA (no OSA group; n = 136). Children who had undergone previous adenotonsillectomy and those with comorbid disorders were excluded from the analysis., Results: Compared with the no OSA group, the OSA group lived in census tracts with lower median family incomes, higher proportions of children living below the Canadian low-income cutoff (indicating poverty), higher proportions of single-parent families, and greater population densities. The highest probability of having OSA was seen in children referred from the most disadvantaged census tracts and was due primarily to moderate/severe OSA. Group differences remained significant when adjusted for age, race/ethnicity, and obesity., Conclusions: Compared with the children without OSA, those with OSA were more likely to reside in disadvantaged neighborhoods. Future studies should examine whether these results can be replicated in other settings, especially those with large socioeconomic disparities., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: A high incidence of respiratory morbidity after adenotonsillectomy is reported in children with obstructive sleep apnea syndrome (OSAS). In an effort to decrease this morbidity, we implemented perioperative guidelines recommending an adjustment in the administration of opioids, dexamethasone, and atropine in children with OSAS who demonstrated recurrent episodes of profound hypoxemia during the perioperative sleep study., Methods: We performed a retrospective review and compared results with historic data from 2001. The primary outcome variable was a major respiratory medical intervention (MMI(Respiratory)). The severity of OSAS was classified with the McGill Oximetry Scoring (MOS) system, and our focus was on those children demonstrating repetitive desaturation <80% (MOS4)., Results: The medical records of 292 children who underwent adenotonsillectomy between October 2002 and February 2006 met the inclusion criteria and 97 had been assigned MOS4. Eleven children (11.3%) required an MMI(Respiratory). In 2001, 8 children (29.6%), assigned MOS4, required an MMI(Respiratory). Comparing the new and old guidelines, the adjusted odds ratio for MMI(Respiratory) in MOS4 was 0.30 (95% CI: 0.10-0.85). The key elements achieving this reduction in MMI(Respiratory) were dexamethasone administration and a reduced opioid dosage. In 2002 to 2006, the intraoperative opioid dose, expressed in morphine equivalents, administered to the MOS4 group was 0.10 mg . kg(-1) (0.06-0.12 mg . kg(-1)), and the postoperative morphine dose was 0.02 mg . kg(-1) (0-0.07 mg . kg(-1)). Both doses were lower than the ones administered to the concurrent comparison group, P values <0.001., Conclusions: A change in practice that included a dexamethasone administration and a reduction in opioid administration to children with profound recurrent hypoxia reduced the incidence of MMI(Respiratory) by >50%.

Background: Polysomnography is the best tool available for diagnosing obstructive sleep apnea (OSA) in children. However, polysomnography is relatively inaccessible and costly, and studies are needed to evaluate other diagnostic approaches. It has been suggested that the OSA-18 quality-of-life questionnaire (OSA-18) is a useful measure that could replace polysomnography. The purpose of our study was to determine if the OSA-18, is an accurate measure for the detection of moderate-to-severe OSA., Patients and Methods: Children who were referred to our sleep laboratory for evaluation of suspected OSA and who had a nocturnal pulse oximetry study were included in our cross-sectional study. The results of the oximetry study were interpreted by using the McGill oximetry score (MOS). Abnormal scores were consistent with moderate-to-severe OSA. We analyzed demographic and medical data in addition to the OSA-18 results. We estimated sensitivity and negative predictive values for the OSA-18 to detect an abnormal MOS. We also conducted logistic regression analyses with MOS as the dependent variable and the OSA-18 score, age, gender, comorbidities, and race as independent variables., Results: We studied 334 children (mean age: 4.6 years; 58% male). The OSA-18 had a sensitivity of 40% and a negative predictive value of 73% for detecting an abnormal MOS. While controlling for other variables in the regression model, for each unit increase in the OSA-18 score, the odds of having an abnormal MOS were increased by 2%. For each 1-year increase in age, the odds of having an abnormal MOS were decreased by 17%., Conclusions: Among children who are referred to a sleep laboratory, the OSA-18 does not accurately detect which children will have an abnormal MOS and cannot be used to exclude moderate-to-severe OSA. The OSA-18 should not be used in the place of objective testing to identify moderate-to-severe OSA in children.

Background: Data suggest that obstructive sleep apnea syndrome (OSA) results in sympathetic stimulation, brady/tachycardia and cardiac stress. Heart rate variability, but not baseline heart rate, is known to be elevated in pediatric OSA. Our patients with moderate to severe OSA (McGill Oximetry Scores of 3 or 4) have been re-evaluated with pulse oximetry after adenotonsillectomy (T&A). We hypothesized that pulse rate (PR) and pulse rate variability (PRV) would decrease after treatment of OSA with T&A., Methods: This retrospective before-after study comprised pre- and post-operative oximetries and parental questionnaires of children 1-18 years old with moderate to severe OSA from September 2004 to August 2005, inclusive. We excluded patients with significant comorbidities., Results: In 25 subjects, age at surgery was 4.3 +/- 3.6 years (mean +/- SD). OSA symptoms decreased or resolved, saturation metrics improved, and parental concern about breathing during sleep decreased following T&A. PR decreased in 21 of 25 patients after T&A (mean PR from 99.7 +/- 11.2 to 90.1 +/- 10.7 bpm, P < 0.001; maximum PR from 150.6 +/- 14.5 to 137.4 +/- 15.6 bpm, P < 0.001). PRV, as measured by the standard deviation of the PR, decreased in 23 of 25 patients after T&A (from 10.3 +/- 2.1 to 8.2 +/- 1.6 bpm, [P < 0.001]). Pulse accelerations greater than 6, 7, 8 bpm also decreased post-operatively., Conclusions: Nocturnal pulse oximetry complements clinical history to document improvement and/or resolution of moderate to severe OSA in children. Resolution of tachycardia and diminished PRV after T&A illustrate the stress that recurrent airway obstruction during sleep places on the cardiovascular system. Further work will be required to determine if PR and PRV as measured by pulse oximetry would be useful in the diagnosis and follow-up of OSA in children., (Copyright 2008 Wiley-Liss, Inc.)

Objective: Current scoring systems, which adjust prediction for severity of illness, do not account for higher observed mortality in neonatal intensive care units (NICUs) of children's hospitals than that of perinatal centers. We hypothesized that three potential predictors, (a) admission from another NICU, (b) presence of congenital anomalies and (c) need for surgery, would modify expected mortality and/or length of stay for infants admitted to NICUs in children's hospitals., Study Design: We reviewed consecutive admissions to two NICUs in children's hospitals in Canada. We performed regression analyses to evaluate these potential predictors and severity-of-illness indices for the outcomes of mortality and length of stay., Result: Of 625 neonatal admissions, transfer from another NICU, congenital anomalies requiring admission and surgery were identified in 371 (59%). Using logistic regression, mortality was predicted based on admission from another NICU (odds ratio (OR) 1.92; 95% confidence interval (CI) 1.04, 3.57), congenital anomalies (OR 7.28; 95% CI 3.69, 14.36) and a validated severity-of-illness score, the Score for Neonatal Acute Physiology Perinatal Extension Version II (SNAPPE-II; OR 1.07; 95% CI 1.05, 1.09 per point). By contrast, surgical intervention was predictive of survival (OR 0.35; 95% CI 0.18, 0.67). Length of stay >or=21 days was predicted by SNAPPE-II (OR 1.02; 95% CI 1.01, 1.03 per point), congenital anomalies (OR 2.47; 95% CI 1.60, 3.79) and surgery (OR 2.73; 95% CI 1.77, 4.21)., Conclusion: Fair performance comparisons of NICUs with different case-mixes, such as children's hospital and perinatal NICUs, in addition to severity-of-illness indices, should account for admissions from another NICU, congenital anomalies and surgery.

Non-nutritive swallowing occurs frequently during sleep in infants and is vital for fluid clearance and airway protection. Swallowing has also been shown to be associated with prolonged apnea in some clinical populations. What is not known is whether swallowing contributes to apnea or may instead help resolve these clinically significant events. We studied the temporal relationships between swallowing, respiratory pauses and arousal in six preterm infants at term using multi-channel polysomnography and a pharyngeal pressure transducer. Results revealed that swallows occurred more frequently during respiratory pauses and arousal than during control periods. They did not trigger the respiratory pause, however, as most swallows (66%) occurred after respiratory pause onset and were often tightly linked to arousal from sleep. Swallows not associated with respiratory pauses (other than the respiratory inhibition to accommodate swallowing) and arousal occurred consistently during the expiratory phase of the breathing cycle. Results suggest that swallowing and associated arousal serve an airway protective role during sleep and medically stable preterm infants exhibit the mature pattern of respiratory-swallowing coordination by the time they reach term.

Objective: To obtain parental perspectives on changes in sleep, breathing, quality of life (QOL), and neurobehavioral measures after adenotonsillectomy., Study Design: This retrospective cohort study comprised otherwise healthy children evaluated for obstructive sleep apnea syndrome (OSAS) from 1993 to 2001. We compared those children who underwent adenotonsillectomy with those children who did not. The parents of 473 children (292 boys) 2 years of age and older were sent questionnaires to evaluate QOL and clinical and behavioral changes. For 94 children 3 years of age and older, behavioral changes were evaluated using the Conners' Parent Rating Scale-Revised (CPRS-R) for three different periods: pre-operatively/pre-polysomnography, postoperatively/postpolysomnography, and recently., Results: One hundred and sixty-six questionnaires were returned (35%), 138 of which were complete with written consent provided. Compared with parents of unoperated children, parents of children who had adenotonsillectomy were more likely to report improvements in sleep, breathing, and QOL but not improvements in concentration, school performance, and intellectual or developmental progress. Both short and long term, there were no significant effects of adenotonsillectomy on any of the CPRS-R behavior subscales., Conclusion: From a parental perspective, adenotonsillectomy frequently improves sleep, breathing, and QOL but does not often improve neurobehavioral outcomes.

Pulmonary lymphangiectasia is a rare cause of respiratory distress in the newborn associated with a very poor outcome. We describe three premature newborns presenting at birth with nonimmune hydrops, bilateral chylothorax, and severe respiratory distress in the immediate newborn period secondary to pulmonary lymphangiectasia. We review the similarities of these cases and discuss their antenatal and neonatal course. One patient survived and is thriving at 9 months of age. With continuing advances in antenatal and neonatal care, an improved outcome may be possible in what was previously described as a uniformly fatal condition., (Copyright 2005 Wiley-Liss, Inc.)

In the past 25 years there has been increasing recognition of obstructive sleep apnoea (OSA) as a common condition of childhood. Morbidity includes impairment of growth, cardiovascular complications, learning impairment, and behavioural problems. Diagnosis and treatment of this condition in children differs in many respects from that in adults. We review here the key features of paediatric OSA, highlighting differences from adult OSA, and suggest future directions for research.

Adenotonsillectomy (T&A) has established effectiveness for the treatment of obstructive sleep apnea (OSA). However, more than 20% of children with OSA have respiratory compromise requiring medical intervention in the postoperative period. The reasons for this complication are not well-defined. We aimed to compare the nature and severity of sleep-disordered breathing in children with mild and severe OSA on the first night following adenotonsillectomy. Ten children were classified into groups of mild and severe OSA, based on preoperative testing. On the first night after T&A, they underwent polysomnography, including electroencephalograph, submental electromyography, bilateral electro-oculograms, monitoring of respiratory movements, heart rate, ECG, and oxygen saturation. Sleep-disordered breathing was assessed by the apnea-hypopnea index, the SaO(2) nadir, and the desaturation index, including dips in saturation below 90% (DI(90)). Sleep quality was assessed by sleep efficiency, time spent in each sleep state, and respiratory arousal index. Obstructive events occurred postoperatively in all children, but were more frequent in those with severe OSA preoperatively: the median (interquartile range) mixed/obstructive apnea/hypopnea indicies were 6.9 (2.2-9.8) events/hr and 21.5 (15.1-112.1) events/hr for the mild OSA group and the severe OSA group, respectively (P = 0.009). Obstructive events were the major cause of desaturation during sleep postoperatively. Sleep quality was severely disrupted in both groups, with reductions in both slow-wave sleep and rapid eye movement sleep. In conclusion, despite removal of obstructing lymphoid tissue, upper airway obstruction occurred on the first postoperative night in children with OSA. This study is the first to demonstrate the mechanism of respiratory compromise after adenotonsillectomy, a common postoperative complication in children with severe OSA., ((c) 2005 Wiley-Liss, Inc.)

Arousals from sleep and consequent sleep disruption may be a causal link between sleep-disordered breathing and its sequellae in children. Quantification of arousals therefore makes an important contribution to the overall assessment of the sleep of a child with suspected obstructive sleep apnea (OSA) or other sleep disorders. Arousals are classically defined by changes in the electroencephalographic (EEG) channels, but most arousals in children involve body movement in addition to EEG changes. Several methods of quantifying arousals without the use of EEG have been proposed, with the aim of simplifying testing in children with suspected OSA so that it can be safely and efficiently performed in the child's home. The following paper gives a background to the assessment of arousals from sleep in children, and describes methods for detecting arousals and their potential application to recordings performed in a child's home.

Prader-Willi syndrome (PWS) is a genetic disorder, with hypotonia being the predominant feature in infancy, and developmental delay, obesity, and behavioral problems becoming more prominent in childhood and adolescence. Children with this disorder frequently suffer from excessive daytime sleepiness and have a primary abnormality of the circadian rhythm of rapid eye movement sleep. They also have primary abnormal ventilatory responses to hypoxia and hypercapnia, and these abnormalities may be exacerbated by obesity. Children with PWS are at risk of a variety of abnormalities of breathing during sleep, including obstructive sleep apnea and sleep-related alveolar hypoventilation. Clinical evaluation should include a careful history of sleep-related symptoms and assessment of the upper airway and lung function. Polysomnography should be considered for those with symptoms suggestive of sleep-disordered breathing. Treatment options depend on the underlying problem, but may include behavioral interventions, weight control, adenotonsillectomy, and nocturnal ventilation., (Copyright 2002 Wiley-Liss, Inc.)

Obstructive sleep apnoea (OSA) is a common condition of childhood with significant associated morbidity. The comprehensive evaluation of children who present with suggestive symptoms involves the overnight recording and assessment of both sleep and respiration by polysomnography in a sleep laboratory. These studies require resources and facilities that are not widely available and thus simpler, more available and less expensive alternatives have been sought. This review discusses the available alternatives to polysomnography for the evaluation of the child with suspected obstructive sleep apnoea.

Obstructive sleep apnea (OSA) is a common condition of childhood, and is associated with significant morbidity. Prevalence of the condition peaks during early childhood, due in part to adenoidal and tonsillar enlargement within a small pharyngeal space. The lymphoid tissues regress after 10 years of age, in the context of ongoing bony growth, and there is an associated fall in the prevalence of OSA. Obstruction of the nasopharynx by adenoidal enlargement promotes pharyngeal airway collapse during sleep, and the presence of large tonsils contributes to airway obstruction. Administration of systemic corticosteroids leads to a reduction in the size of lymphoid tissues due to anti-inflammatory and lympholytic effects. However, a short course of systemic prednisone has been demonstrated not to have a significant effect on adenoidal size or the severity of OSA, and adverse effects preclude the long-term use of this therapy. Intranasal corticosteroids are effective in relieving nasal obstruction in allergic rhinitis, and allergic sensitization is more prevalent among children who snore than among those who do not snore. Intranasal corticosteroids have also been demonstrated to reduce adenoidal size, independent of the individual's atopic status. There is preliminary evidence of an improvement in the severity of OSA in children treated with intranasal corticosteroids, but further studies are needed before such therapy can be routinely recommended. Prescribing clinicians should take into account the potential benefits to the patient, the age of the child, the presence of comorbidities such as allergic rhinitis, the agent used, and the dose and duration of treatment when considering such therapy.

Unlabelled: Newer pulse oximeters have been developed to be motion resistant and thus have few false alarms. However, they have not yet been evaluated in a pediatric sleep laboratory setting. While evaluating new oximeters for use in our laboratory, we obtained simultaneous pulse oximetry data from two Masimo oximeters and from two Nellcor oximeters during nocturnal polysomnography in children referred for sleep-disordered breathing (SDB). In series 1, comprising 24 patients, comparisons were made between a Masimo oximeter with 4-second averaging time and the Nellcor N-200 oximeter set for 3 to 5 second averaging. A maximum of 20 events per patient were randomly selected for analysis, an "event" being a desaturation of > or = 4% registered by either oximeter. Interobserver agreement for event classification was 93%. Eighty-eight percent of 220 desaturation events occurring during wakefulness and 38% of 194 events occurring during sleep were classified as motion artifact on the Nellcor oximeter. Neither the Masimo oximeter nor the transcutaneous oxygen probe confirmed that the desaturation was real, in most of these cases. During sleep, there were 119 events detected by either or both oximeters: 113 (95%) by the Nellcor versus 82 (69%) by the Masimo. For these 119 events, the extent of desaturation was slightly less for the Masimo than the Nellcor oximeter, 4.5 +/- 2.4% versus 5.5 +/- 2.5%, respectively. In series 2, 22 patients were studied comparing a Masimo Radical oximeter with 2 second averaging to the Nellcor N-200 oximeter. The extent of desaturation was slightly greater for the Masimo oximeter. The Masimo oximeter detected more non-artifactual desaturation events occurring during sleep than the Nellcor oximeter, 90% versus 76% (chi2 = 9.9, p < 0.01). In series 3, comprising 128 events in 5 patients, a Nellcor N-395 oximeter detected fewer desaturations during non-movement, sleep periods and had more movement related "desaturation" events, compared to a Masimo Radical oximeter., Conclusions: The Masimo oximeters register many fewer false desaturations due to motion artifact. Using 4-second averaging, a Masimo oximeter detected significantly fewer SaO2 dips than the Nellcor N-200 oximeter but using 2-second averaging, the Masimo oximeter detected more SaO2 dips than the Nellcor N-200 oximeter. The sensitivity and motion artifact rejection characteristics of the Nellcor N-395 oximeter are not adequate for a pediatric sleep laboratory setting. These findings suggest that in a pediatric sleep laboratory, use of a Masimo oximeter with very short averaging time could significantly reduce workload and improve reliability of desaturation detection.

Objective: We tested the hypothesis that a 6-week course of a nasal glucocorticoid spray would decrease the severity of obstructive sleep apnea in children with adenotonsillar hypertrophy., Study Design: We conducted a randomized, triple-blind, placebocontrolled, parallel-group trial of nasal fluticasone propionate versus placebo in 25 children aged 1 to 10 years with obstructive sleep apnea proven on polysomnography. The primary outcome was the change from baseline in the frequency of mixed and obstructive apneas and hypopneas., Results: Thirteen children received fluticasone, and 12 received placebo. The mixed/obstructive apnea/hypopnea index decreased from 10.7 +/- 2.6 (SE) to 5.8 +/- 2.2 in the fluticasone group but increased from 10.9 +/- 2.3 to 13.1 +/- 3.6 in the placebo group, P =.04. The mixed/obstructive apnea/hypopnea index decreased in 12 of 13 subjects treated with fluticasone versus 6 of 12 treated with placebo, P =.03. The frequencies of hemoglobin desaturation and respiratory movement/arousals also decreased more in the fluticasone group. Changes from baseline in tonsillar size, adenoidal size, and symptom score were not significantly different between groups., Conclusion: Nasal fluticasone decreased the frequency of mixed and obstructive apneas and hypopneas, suggesting that topical corticosteroids may be helpful in ameliorating pediatric obstructive sleep apnea.

The prevalence of moderate to severe sleep-disordered breathing (SDB) in patients with myelomeningocele may be as high as 20%, but little information is available regarding treatment of these patients. To assess the efficacy and complications of treatments for these children, we collected data on 73 patients from seven pediatric sleep laboratories. Obstructive sleep apnea (OSA, n = 30) and central apnea (n = 25) occurred more frequently than central hypoventilation (n = 12). We also describe a sleep-exacerbated restrictive lung disease type of SDB in 6 patients who had hypoxemia during sleep without apnea or central hypoventilation. For each type of SDB, effective treatments were identified in a stepwise process, moving towards more complex and invasive therapies. For OSA, adenotonsillectomy was often ineffective (10/14), whereas nasal continuous positive airway pressure (CPAP) was usually successful (18/21). For central apnea, methylxanthines and/or supplemental oxygen proved sufficient in 2 of 9 and 3 of 6, respectively, but noninvasive positive pressure ventilation was required in 7 children. For central hypoventilation, supplemental oxygen (alone or with methylxanthines), noninvasive positive pressure ventilation, and tracheostomy with positive pressure ventilation were effective in 3, 2, and 2 patients, respectively. Sleep-exacerbated restrictive lung disease always required supplemental oxygen treatment, but in 2 cases also required noninvasive positive pressure ventilation; nutritional and orthopedic procedures also were helpful. Posterior fossa decompression was used for the first three types of SDB, but data were insufficient to delineate specific recommendations for or against its use. In summary, evaluation by an experienced, multidisciplinary team can establish an effective treatment regime for a child with myelomeningocele and SDB., (Copyright 2000 Wiley-Liss, Inc.)

Context: In addition to usual prone sleeping, unaccustomed prone sleeping represents a significant risk factor for sudden infant death syndrome (SIDS). However, little information is available regarding the circumstances leading caretakers to change the infant's sleep position to prone position in SIDS victims., Objective: To determine, in a population of SIDS victims, the timing of a change to prone sleeping and the reason for that change in infants who were originally nonprone sleepers., Design and Setting: Case series analysis from a questionnaire administered between 1991 and 1997 to parents and other caretakers of SIDS victims in the province of Quebec (Canada)., Subjects: One hundred fifty-seven SIDS cases occurring in the province during the study., Results: Of the 157 SIDS cases studied, 139 were found in the prone position, although only 93 infants usually slept prone. Of the 64 nonprone sleepers, 34 had been changed to prone by the parents or another caretaker before death, and 18 had apparently turned to prone for the first time. In the 34 cases changed to prone, the change occurred <1 week before death for 21 infants; for 16 of those infants, death occurred the first or second time that they slept prone. In 56% of the cases changed from a nonprone to prone sleeping position, a caretaker other than the parents had precipitated the change., Conclusions: Ongoing campaigns to decrease the risk of SIDS should emphasize the risk of unaccustomed prone sleeping to both parents and secondary caretakers.

Event recording, by differentiating between true and false events, has advanced the diagnosis and management of infants on home cardiorespiratory monitors; however, the pathogenesis of many events remains obscure. To clarify infant behaviours around the time of apnoea/bradycardia alarms, a computerised audiovisual event recording system (CAVERS) triggered by the apnoea/bradycardia recorder, has been developed. The audiovisual recording can begin up to 3 min before the alarm and can continue for up to 3 min after the alarm. CAVERS information is recorded for a total of 65 events in 13 infants. The CAVERS proves most helpful in documenting infant position and the wide variety of behaviours associated with bradycardic events. These behaviours range from sleep or quiet wakefulness to crying and generalised movements. Post-event activity is also highly variable. Interestingly, 20 of 65 events appear to terminate when the infant wakes to the audible monitor alarm. Nursing intervention is documented for 14 of 42 bradycardic events but only one of 23 apnoeic events. The CAVERS, by elucidating infant behaviours, provides information complementary to that given by cardiorespiratory event recording. It is suggested that infant monitors of the future should incorporate both audiovisual and cardiorespiratory data to elucidate optimally apparent life-threatening events, apnoeas and bradycardias.

Objective: To determine the utility of pulse oximetry for diagnosis of obstructive sleep apnea (OSA) in children., Methods: We performed a cross-sectional study of 349 patients referred to a pediatric sleep laboratory for possible OSA. A mixed/obstructive apnea/hypopnea index (MOAHI) greater than or equal to 1 on nocturnal polysomnography (PSG) defined OSA. A sleep laboratory physician read nocturnal oximetry trend and event graphs, blinded to clinical and polysomnographic results. Likelihood ratios were used to determine the change in probability of having OSA before and after oximetry results were known., Results: Of 349 patients, 210 (60%) had OSA as defined polysomnographically. Oximetry trend graphs were classified as positive for OSA in 93 and negative or inconclusive in 256 patients. Of the 93 oximetry results read as positive, PSG confirmed OSA in 90 patients. A positive oximetry trend graph had a likelihood ratio of 19.4, increasing the probability of having OSA from 60% to 97%. The median MOAHI of children with a positive oximetry result was 16.4 (7.5, 30.2). The 3 false-positive oximetry results were all in the subgroup of 92 children who had diagnoses other than adenotonsillar hypertrophy that might have affected breathing during sleep. A negative or inconclusive oximetry result had a likelihood ratio of.58, decreasing the probability of having OSA from 60% to 47%. Interobserver reliability for oximetry readings was very good to excellent (kappa =.80)., Conclusions: In the setting of a child suspected of having OSA, a positive nocturnal oximetry trend graph has at least a 97% positive predictive value. Oximetry could: 1) be the definitive diagnostic test for straightforward OSA attributable to adenotonsillar hypertrophy in children older than 12 months of age, or 2) quickly and inexpensively identify children with a history suggesting sleep-disordered breathing who would require PSG to elucidate the type and severity. A negative oximetry result cannot be used to rule out OSA.

Background: Term infants may die of sudden infant death syndrome (SIDS) when they assume the face-straight-down or the face-near-straight-down head positions. Preterm infants have a higher SIDS rate, but it is not known how often they assume the face-straight-down and face-near-straight-down positions., Objectives: To determine the frequency and cardiorespiratory consequences of head turning and face-down head positioning in prone-sleeping premature infants., Study Design: Supervised overnight cardiorespiratory and audiovisual recordings were conducted in 15 prone-sleeping preterm infants nearing hospital discharge: birth weight, 1178 101 (SEM) g, postconceptional age, 40 1.0 weeks., Results: The preterm infants, studied at a younger postconceptional age than previously reported term infants, seldom turned their heads during sleep; therefore they rarely assumed the face-straight-down position (6 episodes in 3 infants) or the face-near-straight-down position (30 episodes in 6 infants)., Conclusions: Prematurely born infants, known to be at increased risk of SIDS, rarely assume face-down positions when sleeping prone at approximately 40 weeks' postconceptional age. These results suggest that head turning during sleep is developmentally regulated and may have relevance to understanding the age distribution of SIDS.

Moderate to severe sleep-disordered breathing (SDB) was identified in 20% (17 of 83) of children with spina bifida/myelomeningocele (SB/MM) at the Montreal Children's Hospital. The prevalence of SDB in patients with SB/MM elsewhere has not been determined. To establish current practices for identifying SDB in patients with SB/MM, questionnaires were sent to the coordinators of the 212 spina-bifida clinics in Canada and in the United States. Eighty-six (41%) questionnaires were returned, representing data on 13 349 patients. Although 67% of the responding centers reported availability of cardiorespiratory sleep studies, only 996 (7.5%) patients with SB/MM had been tested and only 418 (3.1%) patients had been diagnosed with SDB. Across clinics, the prevalence of SDB was directly related to the frequency of testing. Of 380 deaths over the past 10 years, SDB and sudden unexplained death during sleep were identified as the cause of death in 49 (12.8%) and 34 (8.9%) patients, respectively. Moderate to severe SDB may not have been identified in a significant number of patients with SB/MM because they have not been tested.

Obstructive sleep apnea syndrome (OSAS) in childhood is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns. A spectrum of severity related to the degree of upper airway resistance, to the duration of the disease, to the presence or absence of hypoxemia episodes, and to certain clinical features can be described. Symptomatic children may not fit the criteria for diagnosis established for OSAS in adults; age-specific standards are needed. Both anatomical factors that increase upper airway resistance, e.g. adenotonsillar hypertrophy, and functional processes that decrease upper airway tone, e.g. REM sleep, contribute to the pathogenesis of pediatric OSAS. Sequelae of OSAS in children include neurobehavioural abnormalities, stunting of growth, and cor pulmonale. Both the history and physical examination should target the sleeping child; parents often report loud snoring, difficulty breathing, and obstructive apneas. The gold standard investigation to establish the diagnosis and to quantitate disease severity is overnight polysomnography. Home cardiopulmonary sleep studies have been shown to be an accurate and practical alternative to overnight laboratory polysomnography for routine evaluation of non-complex children with adenotonsillar hypertrophy. Children with documented severe OSAS are at increased post-operative risk for airway compromise and should be observed and monitored carefully. Adenotonsiliectomy is the most common therapy for OSAS in children; as a second-line treatment, the use of nasal CPAP in children with OSAS has been very successful in experienced hands.

Hunter syndrome is one of the mucopolysaccharidoses, characterized by a deficiency of the lysosomal enzyme iduronate sulfatase. Among its physical manifestations, there are numerous head and neck signs, including characteristic facial features, macroglossia and short neck. The accumulation of glycosaminoglycans in the soft tissues of the head and neck can be associated with acute airway obstruction. We report a 7 year old boy with Hunter syndrome who developed acute airway compromise requiring an emergency tracheotomy. A review of the literature of airway management in patients with this disease is also presented.

Objective: To determine the incidence, type, timing, and factors predictive of recurrent significant events in infants with home cardiorespiratory monitors., Study Design: We reviewed data accumulated for 147 patients with an event-recorder type of monitor. The infants were allocated to one of four diagnostic categories: apparent life-threatening events (ALTE, n = 73), former premature infants with persistent apnea and bradycardia (n = 29), siblings of victims of sudden infant death syndrome (SIDS) (n = 24), and parental anxiety after a nonsignificant event (n = 21)., Results: Compliance with monitoring was excellent; the monitors were used on 94% of the prescribed days. Fifty-three (36%) of 147 infants had significant events; of those, 46 (87%) experienced their first event during the first month of monitoring, and 69% of the events occurred during that first month. The most prevalent event type was a bradycardic event. Among infants in the ALTE group, events during the initial investigation period predicted the likelihood of events at home; 2 of the 47 infants (4%) with negative results for an investigation and no events recorded in hospital had apnea, and 4 had a bradycardic event (9%). In contrast, when significant events were recorded in hospital, the events were likely to recur at home (69% and 35% of the infants had apnea or bradycardia, respectively; p < 0.001)., Conclusion: Because most apnea, bradycardia, and recurrent clinical events began during the first month of monitoring, we emphasize the need for vigilant follow-up care of infants immediately after institution of home monitoring. Readmission for investigation is warranted in infants with severe or multiple recurrent events.

Background: Although patients with myelomeningocele and the Chiari II malformation are known to have sleep apnea and respiratory control deficits, the prevalence, types, severities, and associations of sleep-disordered breathing (SDB) have not been adequately defined., Methods: A cross-sectional study of our myelomeningocele clinic population was undertaken to correlate polysomnographic results with historical data and findings from magnetic resonance imaging of the Chiari malformation, pulmonary function results, and nocturnal pulse oximetry., Results: A questionnaire survey of symptoms was available for 107 of 109 children (98% of the clinic population), and 83 patients agreed to undergo overnight polysomnography. Breathing during sleep was classified as normal in 31 cases (37%), mildly abnormal in 35 cases (42%), and moderately/severely abnormal in 17 cases (20%). Among the 17 patients with moderately/severely abnormal SDB, 12 patients had predominantly central apneas and 5 had predominantly obstructive apnea. Patients with a thoracic or thoracolumbar myelomeningocele, those who had previously had a posterior fossa decompression operation, those with more severe brain-stem malformations, and those with pulmonary function abnormalities were more likely to have moderately/severely abnormal SDB, relative risks (95% confidence intervals) 9.2 (2.9 to 29.3), 3.5 (1.3 to 8.9), 3.0 (0.9 to 10.5), and 11.6 (1.6 to 81.3), respectively. Failure of obstructive SDB to resolve after adenotonsillectomy in four patients suggested abnormal control of pharyngeal airway patency during sleep. Nocturnal pulse oximetry accurately predicted moderately/severely abnormal SDB with a sensitivity of 100% and a specificity of 67%., Conclusions: The pathogenesis of SDB in patients with myelomeningocele involves the functional level of the spinal lesions, congenital and acquired brainstem abnormalities, pulmonary function abnormalities, disorders of upper airway maintenance, and sleep state. Polysomnography and nocturnal pulse oximetry should be performed in high-risk patients to detect and classify SDB.

Blood gas measurements and complementary, noninvasive monitoring techniques provide the clinician with information essential to patient assessment, therapeutic decision making, and prognostication. Blood gas measurements are as important for ill newborns as for other critically ill patients, but rapidly changing physiology, difficult access to arterial and mixed venous sampling sites, and small blood volumes present unique challenges. This paper discusses considerations for interpretation of blood gases in the newborn period. Blood gas measurements and noninvasive estimations provide important information about oxygenation. The general goals of oxygen therapy in the neonate are to maintain adequate arterial PaO2 and SaO2, and to minimize cardiac work and the work of breathing. Pulse oximetry and transcutaneous oxygen monitoring are extraordinarily useful techniques of estimating and noninvasively monitoring the neonate's oxygenation, but each method has limitations. Arterial blood gas determinations of pCO2 provide the most accurate determinations of the adequacy of alveolar ventilation, but capillary, transcutaneous, and end-tidal techniques are also useful. An approach to and examples of acid-base disorders are presented. Three hemoglobin variants relevant to the newborn are considered: fetal hemoglobin, carboxyhemoglobin, and methemoglobin. Blood gases obtained in the immediate perinatal period can help assess perinatal asphyxia, but particular attention must be paid to the sampling site, the time of life, and the possible and proven diagnoses.

We developed a portable recording system, suitable for unattended use in a patient's home, that quantitates the essential diagnostic elements of pediatric obstructive sleep apnea syndrome (OSAS): obstructive, mixed and central apneas and hyponeas; hemoglobin saturation, sleep vs. wakefulness; body and head positions; snoring: and sleep disturbance. The present paper reviews validation studies and summarizes two recent studies that demonstrate the unique advantages of performing clinical and research cardiorespiratory sleep studies in the child's home. Development of inexpensive, portable records that integrate audiovisual and physiologic information will make such home recordings more widely available.

Objective: To determine the frequency and physiologic consequences of the face-straight-down (FSD) position, a postulated mechanism for the sudden infant death syndrome in prone-sleeping infants., Study Design: A survey of 151 infants, aged 1 to 7 months, in Montreal showed that 33% slept prone. Ten healthy prone-sleeping infants were studied in their homes at age 10 to 22 weeks. Infrared video and cardiorespiratory recordings were made on 3 consecutive nights in the prone (nights 1 and 3) and lateral (night 2) positions., Results: Infants maintained the prone position during 17 of 19 studies, but only 4 of 9 infants maintained the lateral position. The FSD position was observed 27 times in 17 prone nights: median frequency, 0.6 times per night (interquartile range, 0 to 4), and median total duration, 3.3 minutes (0.8% of total sleep time). A related position, the face-near-straight-down (FNSD) position, occurred more often, 5.3 (1 to 10) time per prone night, for 22.4 minutes (5.8% of total sleep time). Most periods in the FSD and FNSD position had no physiologic consequences; however, 14% of FSD and 3% of FNSD episodes were associated with airway obstruction as indicated by snoring, paradoxical respiratory movements, apnea, and/or increased partial pressure of transcutaneous carbon dioxide. Spontaneous arousal and head turning terminated the FSD and FNSD episodes., Conclusion: The FSD and FNSD positions occur commonly in healthy prone-sleeping infants, and these positions can cause airway obstruction. We speculate that those infants with sudden infant death syndrome found in the FSD or FNSD position either have a congenital or an acquired defect in the arousal-head turning response or have encountered insurmountable environmental factors that prevent effective head turning.