Sleep clinical record: an aid to rapid and accurate diagnosis of paediatric sleep disordered breathing.

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.

Autonomic cardiovascular tests in children with obstructive sleep apnea syndrome.

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.

Food protein-induced allergic proctocolitis in infants: Literature review and proposal of a management protocol.

Food protein-induced allergic proctocolitis (FPIAP) is a condition characterized by inflammatory changes in the distal colon in response to one or more foreign food proteins because of immune-mediated reactions. FPIAP prevalence estimates range widely from 0.16% in healthy children and 64% in patients with blood in stools. In clinical practice, FPIAP is diagnosed when patients respond positively to the elimination of a suspected triggering food allergen. Nevertheless, significant proportions of infants get misdiagnosed with IgE mediated allergy and undergo unnecessary dietary changes. Diagnosis is based on clinical symptoms, a good response to an allergen-free diet and the recurrence of symptoms during the "allergy challenge test". Sometimes clinical features may be non-specific and the etiology of rectal bleeding in childhood may be heterogeneous. Therefore, it is crucial to exclude a variety of other possible causes of rectal bleeding in the pediatric age group, including infection, anal fissure, intestinal intussusception and, in infants, necrotizing enterocolitis and very early onset inflammatory bowel disease. The diagnostic workup includes in those cases invasive procedures such as sigmoidoscopy and colonoscopy with biopsies. The high prevalence of FPIAP contrasts with the lack of known information about the pathogenesis of this condition. For this reason and due to the absence of a review of the evidence, a literature review appears necessary to clarify some aspects of allergic colitis. The aim of the review is to fill this gap and to lay the foundations for a subsequent evidence-based approach to the condition.

Prevalence of EEG paroxysmal activity in a population of children with obstructive sleep apnea syndrome.

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.

Variations in exhaled nitric oxide in children with asthma during a 1-week stay in a mountain village sanatorium.

Knowing about spontaneous variations in the fractional concentration of exhaled nitric oxide (FE(NO)) could improve monitoring of airway inflammation in asthmatic children. We aimed to assess FE(NO) variations (expiratory flow 50 mL/sec) in subjects maintained in similar environmental conditions. We tested spirometry and FE(NO) in symptom-free asthmatic children (9 corticosteroid-naive, 8 corticosteroid-treated) during a 1-week stay in a countryside sanatorium and in their healthy relatives (n = 12) staying in the immediate neighborhood on summer holiday (total 29 children, M/F:14/15, 5.8-16.8 yrs). Testing sessions were repeated every 12 hours (8:00 am, 8:00 pm) for 2 days and again on day 7. Measurements were defined as reproducible when they agreed with an intraclass correlation coefficient (ICC) above 0.60; deviation from mean differences was assessed by the coefficient of repeatability (CR = 2 SD). Lung function remained constant throughout the week in all groups. Baseline FE(NO) levels in corticosteroid-naive asthmatic children tended to decrease at the end of the week (from 13.9 ppb, 95% CI 12.2-19.1 to 9.2 ppb, 95% CI 5.8-15.9, p = 0.057). No differences were found between nocturnal and diurnal FE(NO). Within-session reproducibility for two FE(NO) measurements was high (ICC 0.99 in all groups and CR, 0.9 to 1.3 ppb). Between-session FE(NO) reproducibility at 12 hours and 24 hours was still high for each group but decreased markedly after 6 days in corticosteroid-naive asthmatic children (ICC 0.79 and CR 9.6 ppb at 24 hours vs. ICC 0.13 and CR 20.8 ppb after 6 days), whereas it decreased slightly in corticosteroid-treated asthmatics (from ICC 0.89 and CR 3.1 ppb to ICC 0.88 and CR 3.0 ppb) and healthy children (from ICC 0.79 and CR 4.8 ppb to ICC 0.65 and CR 5.7 ppb). In conclusion, in healthy subjects and in asthmatic children receiving therapy with inhaled corticosteroids (but not in corticosteroid-naive subjects), FE(NO) measurements are reproducible across a week.

Preventive nasal bacteriotherapy for the treatment of upper respiratory tract infections and sleep disordered breathing in children.

OBJECTIVES: The purpose of this prospective study was to assess the effectiveness and safety of Streptococcus salivarius 24SMBc administered as a nasal spray in children affected by recurring infections of the upper airways, adenotonsillar hypertrophy, and sleep disordered breathing (SDB). METHODS: Prospective study on 42 children with SDB. Anamnestic and general examination data were collected using the 'Sleep Clinical Record' (SCR) questionnaire during the first inspection and after three months of treatment with Streptococcus salivarius 24SMBc nasal spray. Quantitative variables were statistically compared. RESULTS: After three months, the enrolled patients showed lower SCR scores than during the first inspection (6.0 vs 7.5 p < 0.000), with a significant reduction of nasal obstruction (p = 0.001) and oral breathing (p = 0.04), and a positive Brouillette Score (p = 0.001). The children and parents did not declare any adverse reactions during the three months of treatment. CONCLUSIONS: This series confirms the effectiveness and safety of Streptococcus salivarius 24SMBc treatment in children affected by recurring upper respiratory tract infections, adenotonsillar hypertrophy, and sleep disordered breathing.

Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up.

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.

Reduced exhaled nitric oxide in children after testing of maximal expiratory pressures.

Spirometry in adult subjects can induce a fall in concentration of exhaled nitric oxide (FE(NO)). Scarce information is available on the FE(NO) decrease after spirometry or after other forced lung-function maneuvers in children. We compared changes in FE(NO) induced by repeated spirometry and testing of maximal expiratory pressures (P(Emax)). Twenty-four sex- and age-matched children aged 9-18 years (mean age +/- SD, 13.3 +/- 2.8 years; 12 healthy, 12 asthmatic) were allocated to 1-week-apart sessions of repeated maneuvers of either forced vital capacity (FVC) or P(Emax). Baseline FE(NO) measurements were followed by FVC or P(Emax) maneuvers every 15 min for 45 min, whereas FE(NO) was measured at each step for 60 min. After repeated P(Emax) but not after FVC maneuvers, FE(NO) values decreased significantly from baseline in both groups. In healthy children, geometric mean FE(NO) (95% confidence intervals) decreased from 9.1 (7.0-11.8) ppb at baseline to 8.2 (6.3-10.6) ppb at 15 min and 7.7 (5.6-10.6) ppb at 30 min (P < 0.05 and P < 0.01, respectively), and remained unchanged at 45 and 60 min. In asthmatic children, FE(NO) levels fell from 21.6 (13.3-34.9) ppb at baseline to 15.1 (9.1-25.1) ppb at 15 min and remained low at 30, 45, and 60 min: 17.8 (10.7-29.5) ppb, 17.5 (10.2-30.1) ppb, and 17.6 (10.6-29.2) ppb, P < 0.01, for all differences from baseline. Repeated P(Emax) and FVC maneuvers increased FE(NO) variability, as compared with repeated FE(NO) measurements alone. Previous forced lung-function maneuvers may affect FE(NO) measurements in children. Although P(Emax) testing has a greater influence than spirometry on FE(NO) levels in children, both procedures should be avoided before measuring FE(NO).

Oximetry in obese children with sleep-disordered breathing.

BACKGROUND: Obesity is an important risk factor for obstructive sleep apnea syndrome (OSAS), and obese children with OSAS have frequently shown oxygen desaturations when compared with normal-weight children. The aim of our study was to investigate the oximetry characteristics in children with obesity and sleep-disordered breathing (SDB). METHODS: Children referred for suspected OSAS were enrolled in the study. All children underwent sleep clinical record (SCR), pulse oximetry, and polysomnography (PSG). RESULTS: A total of 248 children with SDB were recruited (128 obese and 120 normal-weight children). Obese children showed higher oxygen desaturation index (ODI) and lower nadir oxygen saturation (nadir SaO2) compared to non-obese children (p < 0.05). ODI and nadir SaO2 correlated with obesity (p < 0.05). The SCR evaluation showed that deep bite and overjet were more common among obese children (p < 0.05), whereas habitual nasal obstruction and arched palate were more common among non-obese children (p < 0.05). Furthermore, skeletal malocclusion and tonsillar hypertrophy were significant risk factors in obese children associated with severe desaturation (p < 0.05). CONCLUSION: Obese children with SDB have a more significant oxygen desaturation; adeno-tonsillar hypertrophy is not the only important risk factor for its development but also the presence of malocclusions.

Sleep clinical record: what differences in school and preschool children?

The sleep clinical record (SCR) may be a valid method for detecting children with obstructive sleep apnoea (OSA). This study aimed to evaluate whether there were differences in SCR depending on age and to identify the possible risk factors for OSA development. We enrolled children with sleep disordered breathing between 2013 and 2015, and divided them according to age into preschool- and school-age groups. All patients underwent SCR and polysomnography. OSA was detected in 81.1% and 83.6% of preschool- and school-age groups, respectively. Obesity, malocclusions, nasal septal deviation and inferior turbinate hypertrophy were significantly more prevalent in school-age children (p<0.05); however, only tonsillar hypertrophy had significant hazard ratio (2.3) for OSA development. Saddle nose, nasal hypotonia, oral breathing and tonsillar hypertrophy were significantly more prevalent for development of OSA in preschoolers (p<0.03). The SCR score was significantly higher among preschool children than in school-age children (8.4±2.22 versus 7.9±2.6; p=0.044). Further, SCR score >6.5 had a sensitivity of 74% in predicting OSA in preschool children with positive predictive value of 86% (p=0.0001). Our study confirms the validity of the SCR as a screening tool for patient candidates for a PSG study for suspected OSA, in both school and preschool children.

Sleep cyclic alternating pattern analysis in infants with apparent life-threatening events: a daytime polysomnographic study.

OBJECTIVE: Non-REM sleep is characterized by a physiologic oscillating pattern that exhibits different levels of arousal, coded as cyclic alternating pattern. The aim of this study was to analyze the development of cyclic alternating pattern parameters in a group of infants with apparent life-threatening events. METHODS: A total of 26 infants with apparent life-threatening events (14 females, mean age 3.4 months, 2.37 S.D., age range 0.5-9 months) were studied while they slept in the morning between feedings, by means of a 3-h video-electroencephalographic-polygraphic recording. Sleep was visually scored using standard criteria. The control group was composed of 36 healthy infants (16 females, mean age 3.2 months, 2.17 S.D., age range 0.5-9 months). RESULTS: Children with apparent life-threatening events showed an increased frequency of periodic breathing, gastroesofageal reflux and of other risk conditions. They presented also an increased obstructive apnoea/hypopnea index. A full NREM sleep development was found in a significantly smaller percentage of patients, and they showed a significant reduction of the percentage of REM sleep, of cyclic alternating pattern A1 subtypes, an increased percentage of A2 and A3 subtypes and increased index of A2, A3 subtypes and arousal, compared to normal controls. Cyclic alternating pattern rate showed a significant positive correlation with age, only in controls. CONCLUSIONS: Our results show a higher level of arousal and an increased non-REM sleep discontinuity in babies with apparent life-threatening events, compared to controls. SIGNIFICANCE: The enhanced mechanism of arousal might counteract life-threatening events and represent an important neurophysiologic distinction from future victims of sudden infant death syndrome who also experience similar events.

Sleep cyclic alternating pattern analysis in healthy children during the first year of life: a daytime polysomnographic study.

We evaluated the cyclic alternating pattern (CAP) during the first year of life in order to obtain information on the maturation of arousal mechanisms during NREM sleep and to provide normative data for CAP parameters in this age range (5-16months). Eleven healthy children (mean age 7.9±3.3months, seven boys) were studied while they slept in the morning. They underwent a 3-h video-EEG-polysomnographic recording at the Pediatric Sleep Unit of Sant'Andrea Hospital in Rome, Italy. Sleep was scored visually for sleep architecture and CAP analysis using standard criteria. Our results were complemented by CAP data from a previous sample of healthy infants (2-4months), studied when they slept during the morning, in order to correlate CAP parameters with age. The total sample comprised 24 children. The sleep period was approximately 2h, with a first REM latency of about 30min, and a clear distinction between stages N1, N2, and N3. The arousal index was 12±2.1 events/hour of sleep. The total CAP rate was 23.7±7.6%, and it increased progressively with the deepness of sleep; the highest values were observed during stage N3 and the lowest values during stage N1. A1 phases were the most numerous (78.2%), followed by A2 (14%) and A3 (7.7%) phases. The A1 index was higher than the A2 and A3 indices, whereas the mean duration of B was higher than that of A. The correlation showed that the CAP rate, A1, A2, A3 indices, A2, A3 percentages, and the average duration of B increased with age, whereas the A1 percentage decreased. We provide the first data on CAP analysis in children aged 5-16months, studied when they slept during the morning. Our results confirm the trend toward an increase in CAP rate during the first year of life. In addition, we observed a progressive increase in CAP rate with deepness of sleep, and with age, reflecting maturation of slow-wave activity. The decreased percentage of A1 subtypes may reflect the maturation of arousability.

Additive effect of eosinophilia and atopy on exhaled nitric oxide levels in children with or without a history of respiratory symptoms.

Although atopy and blood eosinophilia both influence exhaled nitric oxide (eNO) measurements, no study has quantified their single or combined effect. We assessed the combined effect of atopy and blood eosinophilia on eNO in unselected schoolchildren. In 356 schoolchildren (boys/girls: 168/188) aged 9.0-11.5 yr, we determined eNO, total serum IgE, blood eosinophil counts and did skin prick tests (SPT) and spirometry. Parents completed a questionnaire on their children's current or past respiratory symptoms. Atopy was defined by a SPT >3 mm and eosinophilia by a blood cell count above the 80th percentile (>310 cells/ml). eNO levels were about twofold higher in atopic-eosinophilic subjects than in atopic subjects with low blood eosinophils [24.3 p.p.b. (parts per billion) vs. 14.1 p.p.b.] and than non-atopic subjects with high or low blood eosinophils (24.3 p.p.b. vs. 12.2 p.p.b. and 10.9 p.p.b.) (p <0.001 for both comparisons). The additive effect of atopy and high eosinophil count on eNO levels remained unchanged when subjects were analyzed separately by sex or by a positive history of wheeze (n=60), respiratory symptoms other than wheeze (n=107) or without respiratory symptoms (n=189). The frequency of sensitization to Dermatophagoides (Dpt or Dpf) was similar in atopic children with and without eosinophilia (66.2% and 67.4%, respectively); eosinophilia significantly increased eNO levels in Dp-sensitized children as well in children sensitized to other allergens. In a multiple linear regression analysis, eNO levels were mainly explained by the sum of positive SPT wheals and a high blood eosinophil count (t=4.8 and 4.3, p=0.000), but also by the presence of respiratory symptoms (especially wheeze) and male sex (t=2.6 and 2.0, p=0.009 and 0.045, respectively). Measuring eNO could be a simple, non-invasive method for identifying subjects at risk of asthma in unselected school populations.

Randomized controlled study of an oral jaw-positioning appliance for the treatment of obstructive sleep apnea in children with malocclusion.

To evaluate the clinical usefulness and tolerability of an oral jaw-positioning appliance in the treatment of obstructive sleep apnea syndrome in children, we studied 32 patients (mean age, 7.1 +/- 2.6 yr; 20 males) with symptoms of obstructive sleep apnea, malocclusion, and a baseline apnea index > 1 event/h. A group of 19 subjects was randomly assigned to a 6-mo trial of an oral appliance; the remainder acted as control subjects. At baseline and after the trial all patients underwent physical examination, a standard polysomnography, and orthodontic assessment. A modified version of the Brouillette questionnaire related to obstructive sleep apnea symptoms was administered to parents before and after the trial and a clinical score was calculated. Of the 32 subjects enrolled, 4 treated subjects and 5 control subjects were lost to follow-up. Polysomnography after the trial showed that treated subjects all had significantly lower apnea index (p < 0.001) and hypopnea index values (p < 0.001) than before the trial, whereas in untreated control subjects these values remained almost unchanged. Clinical assessment before and after treatment showed that in 7 of the 14 subjects (50%) the oral appliance had reduced (a fall of at least 2 points in the respiratory score) and in 7 had resolved the main respiratory symptoms, whereas untreated patients continued to have symptoms. In conclusion, treatment of obstructive sleep apnea syndrome with an oral appliance in children with malocclusion is effective and well tolerated.