Detection of Postpartum Hemorrhage Using Compensatory Reserve Index in Patients Undergoing Cesarean Delivery.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Early recognition and management are imperative for improved outcomes. The compensatory reserve index (CRI) is a novel physiological parameter that trends changes in intravascular volume, by continuously comparing extracted photoplethysmogram waveforms to a reference model that was derived from a human model of acute blood loss. This study sought to determine whether the CRI pattern was differential between those who do and do not experience PPH during cesarean delivery and compare these results to the American Society of Anesthesiologists (ASA) standards for noninvasive monitoring. METHODS: Parturients undergoing cesarean delivery were enrolled between February 2020 and May 2021. A noninvasive CRI monitor was applied to collect continuous CRI values throughout the intraoperative and immediate postpartum periods. Patients were stratified based on blood loss into PPH versus non-PPH groups. PPH was defined as a quantitative blood loss >1000 mL. Function-on-scalar (FoS) regression was used to compare trends in CRI between groups (PPH versus non-PPH) during the 10 to 60-minute window after delivery. Two subanalyses excluding patients who received general anesthesia and preeclamptics were performed. RESULTS: Fifty-one patients were enrolled in the study. Thirteen (25.5%) patients experienced PPH. Pregnant patients who experienced PPH had, on average, lower postdelivery CRI values (-0.13; 95% CI, -0.13 to -0.12; P < .001) than those who did not experience PPH. This persisted even when adjusting for preeclampsia and administration of uterotonics. The average mean arterial pressure (MAP) measurements were not statistically significant (-1.67; 95% CI, -3.57 to 0.22; P = .09). Similar trends were seen when excluding patients who underwent general anesthesia. When excluding preeclamptics, CRI values remained lower in those who hemorrhaged (-0.18; 95% CI, -0.19 to -0.17; P < .001). CONCLUSIONS: CRI detects changes in central volume status not distinguished by MAP. It has the potential to serve as a continuous, informative metric, notifying providers of acute changes in central volume status due to PPH during cesarean delivery.

Effect of Routine Child Physical Abuse Screening Tool on Emergency Department Efficiency.

OBJECTIVES: Physical abuse is a significant cause of morbidity and mortality for children. Routine screening by emergency nurses has been proposed to improve recognition, but the effect on emergency department (ED) workflow has not yet been assessed. We sought to evaluate the feasibility of routine screening and its effect on length of stay in a network of general EDs. METHODS: A 2-question child physical abuse screening tool was deployed for children <6 years old who presented for care in a system of 27 general EDs. Data were compared for the 6 months before and after screening was deployed (4/1/2019-10/2/2019 vs 10/3/2019-3/31/2020). The main outcome was ED length of stay in minutes. RESULTS: There were 14,133 eligible visits in the prescreening period and 16,993 in the screening period. Screening was completed for 13,404 visits (78.9%), with 116 (0.7%) screening positive. The mean ED length of stay was not significantly different in the prescreening (95.9 minutes) and screening periods (95.2 minutes; difference, 0.7 minutes; 95% CI, -1.5, 2.8). Among those who screened positive, 29% were reported to child protective services. On multivariable analysis, implementation of the screening tool did not impact overall ED length of stay. There were no significant differences in resource utilization between the prescreening and screening periods. CONCLUSIONS: Routine screening identifies children at high risk of physical abuse without increasing ED length of stay or resource utilization. Next steps will include determining rates of subsequent serious physical abuse in children with or without routine screening.

Outcomes in Pediatric Trauma Patients Who Receive Blood Transfusion.

INTRODUCTION: Increased blood volumes, due to massive transfusion (MT), are known to be associated with both infectious and noninfectious adverse outcomes. The aim of this study was to assess the association between MT and outcomes in pediatric trauma patients, and, secondarily, determine if these outcomes are differential by age once MT is reached. METHODS: Pediatric patients (ages 1-18 y old) in the ACS pediatric Trauma Quality Improvement Program (TQIP) database (2015-2018) who received blood were included. Patients were stratified by MT status, which was defined as blood product volume of 40 mL/kg within 24 h of admission (MT+) and compared to children who received blood products but did not meet the MT threshold (MT-). Defined MT + patients were matched 1:1 to MT-patients via propensity score matching of characteristics before comparisons. Adjusted logistic regression was performed on univariably significant outcomes of interest. RESULTS: There were 2318 patients in the analytic cohort. Patients who received MT had higher rates of deep venous thrombosis (DVT) (2.5% versus 1.0%, P < 0.001), acute kidney injury (AKI) (1.5% versus 0.0%, P = 0.022), CLABSI (4.0% versus 2.0% P = 0.008), and severe sepsis (2.3% versus. 1.1%, P = 0.02). On logistic regression MT was an independent risk factor for these outcomes. There was no differential effect of MT on these outcomes based on age. CONCLUSIONS: Outcomes associated with blood transfusion in pediatric trauma patients are low overall, but rates of DVT, AKI, CLABSI, and sepsis are higher in those who receive MT+ with no differences based on age.

Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients.

INTRODUCTION: The Social Vulnerability Index (SVI) is a composite measure geocoded at the census tract level that has the potential to identify target populations at risk for postoperative surgical morbidity. We applied the SVI to examine demographics and disparities in surgical outcomes in pediatric trauma patients. METHODS: Surgical pediatric trauma patients (≤18-year-old) at our institution from 2010 to 2020 were included. Patients were geocoded to identify their census tract of residence and estimated SVI and were stratified into high (≥70th percentile) and low (<70th percentile) SVI groups. Demographics, clinical data, and outcomes were compared using Kruskal-Wallis and Fisher's exact tests. RESULTS: Of 355 patients included, 21.4% had high SVI percentiles while 78.6% had low SVI percentiles. Patients with high SVI were more likely to have government insurance (73.7% versus 37.2%, P < 0.001), be of minority race (49.8% versus 19.1%, P < 0.001), present with penetrating injuries (32.9% versus 19.7%, P = 0.007), and develop surgical site infections (3.9% versus 0.4%, P = 0.03) compared to the low SVI group. CONCLUSIONS: The SVI has the potential to examine health care disparities in pediatric trauma patients and identify discrete at-risk target populations for preventative resources allocation and intervention. Future studies are necessary to determine the utility of this tool in additional pediatric cohorts.

Retrospective chart review of patient socioeconomic status and language preference associated with live video telehealth in a pediatric dermatology practice.

Pediatric teledermatology rapidly expanded with the COVID-19 pandemic, and the impacts of this expansion on patients' access to care have not yet been entirely defined. In this retrospective study of 3027 patients in an academic pediatric dermatology practice, patients who identified as having a primary language other than English were less likely to access pediatric dermatology care during the COVID lockdown. This study did not identify a significant or meaningful difference in age, geography, socioeconomic status, ethnicity, or race between patients who were offered pediatric dermatology care that was either in-person or via synchronous telehealth. These findings are overall reassuring that there were not major disparities in telehealth utilization during the COVID shelter-in-place mandate, although highlight the need for institutions to ensure systems are in place to enhance telehealth access for patients with non-English primary language.

Factors Which May Contribute to the Success or Failure of the Use of Mother's Own Milk in a Level IV Neonatal Intensive Care Unit.

BACKGROUND: Benefits of mother's own milk (MOM) for infants in neonatal intensive care units (NICUs) are well known. Many mothers provide for their infant's feedings during their entire hospitalization while others are unable. Knowledge is limited about which infant and maternal factors may contribute most to cessation of MOM feedings. PURPOSE: Study aims were to (1) identify which maternal and infant risk factors or combination of factors are associated with cessation of provision of MOM during hospitalization, (2) develop a lactation risk tool to identify neonatal intensive care unit infants at higher risk of not receiving MOM during hospitalization, and (3) identify when infants stop receiving MOM during hospitalization. METHODS: A data set of 797 infants admitted into a level IV neonatal intensive care unit before 7 days of age, whose mothers chose to provide MOM, was created from analysis of data from the Children's Hospital Neonatal Database. Maternal and infant factors of 701 dyads who received MOM at discharge were compared with 87 dyads who discontinued use of MOM by discharge using χ 2 , t tests, and Wilcoxon rank tests. Logistic regression was used to build a risk-scoring model. RESULTS: The probability of cessation of MOM increased significantly with the number of maternal-infant risk factors. A Risk Calculator was developed to identify dyads at higher risk for cessation of MOM by discharge. IMPLICATIONS FOR PRACTICE: Identifying mothers at risk for cessation of MOM can enable the healthcare team to provide optimal lactation management and outcomes. IMPLICATIONS FOR RESEARCH: Although the Risk Calculator has potential to identify dyads at risk of early MOM cessation, further research is needed to validate these results.

Evaluation of problem-based learning in dental trauma education: An observational cohort study.

BACKGROUND/AIM: Problem-based learning (PBL) allows higher thinking among dental students and has improved first-time pass-rates in predoctoral pediatric dentistry education. The aim of this retrospective observational cohort study was to evaluate the impact of PBL-based, traumatic dental injuries case discussions on predoctoral dental trauma education. MATERIALS AND METHODS: Student performance and perceptions after receiving dental trauma curriculum with or without PBL-based dental trauma case discussions were evaluated. All the students challenged their simulated patient-based assessments. Three recall-based, objective structured clinical examinations, and critical thinking competencies assessed student knowledge about management of traumatic injuries affecting primary or permanent dentition including avulsion. The scores and number of attempts for each competency were compared between the study cohorts using t-tests. Student's self-perceived learning outcomes were measured through a voluntary, five-question survey. Mantel-Haenszel ordinal Chi-square tests were used to assess for differences in rates of agreement on survey responses from the students. Linear regression was used to assess effect of training on scores adjusting for student type (predoctoral or advanced standing). Pearson's correlations were used to assess association between scores. Significance was set at 0.05. RESULTS: For the PBL cohort, there was a significant (p > 0.05) improvement in the first-time pass-rates and scores in three out of four competencies. A higher proportion of students in the PBL cohort perceived that their dental trauma education improved their radiographic and diagnostic skills compared to the cohort that did not receive PBL (p > 0.05). There was no correlation between recall-memory versus critical thinking competencies (r < 0.5). CONCLUSION: The PBL-based dental trauma case discussion had a positive impact on predoctoral student learning and perceived benefits while managing simulated traumatic dental injuries. Due to a lack of correlation between recall-memory and critical thinking assessments, evaluation of predoctoral student's dental trauma competencies should involve multi-model assessment.

Electrolyte derangements in critically ill children receiving balanced versus unbalanced crystalloid fluid resuscitation.

BACKGROUND: Adult studies have demonstrated potential harm from resuscitation with 0.9% sodium chloride (0.9%NaCl), resulting in increased utilization of balanced crystalloids like lactated ringers (LR). The sodium and potassium content of LR has resulted in theoretical safety concerns, although limited data exists in pediatrics. We hypothesized that use of LR for resuscitation would not be associated with increased electrolyte derangements compared to 0.9%NaCl. METHODS: A prospective, observational cohort study of critically ill children who received ≥ 20 ml/kg of fluid resuscitation and were admitted to two pediatric intensive care units from November 2017 to February 2020. Fluid groups included patients who received > 75% of fluids from 0.9%NaCl, > 75% of fluids from LR, and a mixed group. The primary outcome was incidence of electrolyte derangements (sodium, chloride, potassium) and acidosis. RESULTS: Among 559 patients, 297 (53%) received predominantly 0.9%NaCl, 74 (13%) received predominantly LR, and 188 (34%) received a mixture. Extreme hyperkalemia (potassium ≥ 6 mmol/L) was more common in 0.9%NaCl group (5.8%) compared to LR group (0%), p 0.05. Extreme acidosis (pH > 7.1) was more common in 0.9%NaCl group (11%) compared to LR group (1.6%), p 0.016. CONCLUSIONS: LR is associated with fewer electrolyte derangements compared to 0.9%NaCl. Prospective interventional trials are needed to validate these findings.

When is synchronous telehealth acceptable for pediatric dermatology?

BACKGROUND/OBJECTIVES: We evaluated the acceptance of synchronous (live video) telehealth for pediatric dermatology. METHODS: This was a prospective, single-center study of patient and dermatologist surveys paired at the encounter level for telehealth encounters with Children's Hospital Colorado Pediatric Dermatology Clinic between 21 April 2020 and 22 May 2020. RESULTS: Dermatologists were most receptive to a telehealth encounter for isotretinoin monitoring (96.6%) and non-isotretinoin acne (89.5%). In contrast, 71.8% and 58.8% of patients surveyed were open to telehealth for isotretinoin encounters and non-isotretinoin acne encounters, respectively. There was no significant correlation between patient and dermatologist satisfaction regarding a telehealth encounter (r = 0.09, CI [-0.09, 0.26], p = .34) or between patient and dermatologist preference for telehealth encounter (r = 0.07, CI [-0.11, 0.25] p = .46). Dermatologists reported needing a photo to aid their physical examination in 38/363 (10.7%) of encounters and preferred in-person examinations when an encounter would have benefitted from laboratories, procedures, dermatoscopic examination, examination by palpation, and accurate weights in infants. CONCLUSIONS: Synchronous, live-video telehealth is an effective method of healthcare delivery in certain situations for pediatric dermatology, but it does not replace in-person encounters. Families and dermatologists have different perceptions about its acceptance.

To give or not to give? Blood for pediatric trauma patients prior to pediatric trauma center arrival.

PURPOSE: This study evaluates the indications, safety and clinical outcomes associated with the administration of blood products prior to arrival at a pediatric trauma center (prePTC). METHODS: Children (≤ 18 years) who were highest level activations at an ACS level 1 pediatric trauma center (PTC) from 2009-2019 were divided into groups:(1) patients with transport times < 4 h who received blood prePTC(preBlood) versus (2) age matched controls with transport times < 4 h who only received crystalloid prePTC (preCrystalloid). RESULTS: Of 1269 trauma activations, 38 met preBlood and 38 met preCrystalloid inclusion criteria. A similar volume of prePTC crystalloid infusion was observed between cohorts (p = 0.311). PreBlood patients evidenced greater hemodynamic instability as demonstrated by higher prePTC pediatric age-adjusted shock index (SIPA) scores. PreBlood patients showed improvement in lactate (p = 0.038) and hemoglobin (p = 0.041) levels upon PTC arrival. PreBlood patients received less crystalloid within 12 h of PTC admission (p = 0.017). No significant differences were found in blood transfusion volumes within six (p = 0.293) and twenty-four (p = 0.575) hours of admission, nor in mortality between cohorts (p = 0.091). CONCLUSIONS: The administration of blood to pediatric trauma patients prior to arrival at a PTC is safe, transiently improves markers of shock, and was not associated with worse outcomes.

Social media communities for patients and families affected by congenital pediatric surgical conditions.

BACKGROUND: Social media has become a means to allow individuals affected by rare diseases to connect with others. This study aimed to characterize the use of three popular social media platforms by individuals affected by common pediatric surgery index conditions. METHODS: A systematic search of Instagram, Facebook, and Twitter was performed using standardized terms for the following pediatric surgical conditions: anorectal malformation, biliary atresia, bronchopulmonary sequestration, congenital diaphragmatic hernia (CDH), congenital pulmonary airway malformation, duodenal atresia, esophageal atresia/tracheoesophageal fistula (EA/TEF), gastroschisis, Hirschsprung disease (HD), and omphalocele. Accounts active within the last year were analyzed and assessed. RESULTS: A total of 666 accounts were identified. Instagram was the most common platform, but accounts dedicated to support and story sharing were most common on Facebook. Biliary atresia and CDH had the largest communities identified. Support groups were most common among those dedicated to EA/TEF (43.3%, p < 0.001). Most accounts were created by parents, but accounts dedicated to HD had the greatest proportion founded by patients (22.4%, p = 0.04). CONCLUSIONS: Social media use is common among patients and families affected by congenital surgical conditions. Certain diseases have larger communities and support networks. Knowledge about their existence may allow surgeons to direct patients towards supportive communities and resources. LEVEL OF EVIDENCE: IV.

The use of social media among the pediatric colorectal community.

PURPOSE: Pediatric colorectal conditions require complex medical care and can require lifelong support. Caregivers often seek medical information on the internet. The aim of this study was to characterize the use of three social media platforms for information sharing about pediatric colorectal conditions. METHODS: A systematic study of Instagram, Facebook, and Twitter was performed using standardized search terms. Accounts with activity within the last year were included. Quantitative data were collected. Accounts were qualitatively assessed and assigned a functional category. Group differences were tested via Kruskal-Wallis test and Fisher's exact tests for continuous and categorical variables, respectively. RESULTS: A total of 96 Instagram accounts, 57 Twitter accounts, 49 Facebook pages, and 45 Facebook groups were identified. Accounts originated from 24 countries and the greatest number of accounts was created in 2013. The most common source of information on Instagram was from personal accounts (74.0%), on Facebook was from support groups (45.7%), and on Twitter was from health care providers (35.1%), (p < 0.001). The most common functional categories on Instagram were personal story (69.8%), on Twitter were scientific information/medical research (57.9%), and on Facebook were supportive/story sharing (47.8%), (p < 0.001). CONCLUSIONS: Social media serves as a source for medical information and allows for supportive communities for pediatric colorectal patients and their families to exist.

Advanced glycation end product intake during pregnancy and offspring allergy outcomes: A Prospective cohort study.

BACKGROUND: Associations have been shown between concurrent assessment of dietary intake of advanced glycation end products (AGEs) and childhood allergic outcomes. We examined the association between maternal AGEs intake and development of offspring asthma, wheeze, atopic dermatitis, allergic rhinitis and food allergies, and sought to determine whether the intake of AGEs was associated with cord sera cytokines/chemokines. METHODS: Pregnant women ≥16 years were recruited in the Healthy Start study, a prospective pre-birth cohort from Colorado (N = 1410). The analysis included 962 dyads with adequate diet (≥2 recalls) and allergy outcome details. AGEs intake was estimated for each mother by matching intakes reported using 24-h dietary recalls during pregnancy to a reference database of commonly consumed foods' AGEs values. Child diagnoses of asthma and allergies up to 8 years were obtained from electronic medical records. Cord sera cytokines and chemokines were analysed in a subset (N = 462) of children. RESULTS: The median [IQR] AGEs intake for the overall sample was 11,919 kU/day [8293, 16,573]. Unadjusted analysis showed a positive association between maternal AGEs intake in pregnancy and rhinitis up to 8 years of age (HR = 1.03; 95% CI: 1.01, 1.06), but the association was attenuated and no longer significant in adjusted models (HR = 1.01; 95% CI: 0.98, 1.04). Both adjusted and unadjusted models showed no associations between AGEs intake in pregnancy and any of the other outcomes (p > .05). There were no significant associations between any cytokine or chemokine measured and AGEs intake or any of the outcomes studied (p > .05). CONCLUSION: The study showed that maternal AGEs intake was not associated with offspring asthma and allergy outcomes. AGEs exposure during pregnancy may not have the same impact on child development as postnatal exposure.

Random survival forests for dynamic predictions of a time-to-event outcome using a longitudinal biomarker.

BACKGROUND: Risk prediction models for time-to-event outcomes play a vital role in personalized decision-making. A patient's biomarker values, such as medical lab results, are often measured over time but traditional prediction models ignore their longitudinal nature, using only baseline information. Dynamic prediction incorporates longitudinal information to produce updated survival predictions during follow-up. Existing methods for dynamic prediction include joint modeling, which often suffers from computational complexity and poor performance under misspecification, and landmarking, which has a straightforward implementation but typically relies on a proportional hazards model. Random survival forests (RSF), a machine learning algorithm for time-to-event outcomes, can capture complex relationships between the predictors and survival without requiring prior specification and has been shown to have superior predictive performance. METHODS: We propose an alternative approach for dynamic prediction using random survival forests in a landmarking framework. With a simulation study, we compared the predictive performance of our proposed method with Cox landmarking and joint modeling in situations where the proportional hazards assumption does not hold and the longitudinal marker(s) have a complex relationship with the survival outcome. We illustrated the use of the RSF landmark approach in two clinical applications to assess the performance of various RSF model building decisions and to demonstrate its use in obtaining dynamic predictions. RESULTS: In simulation studies, RSF landmarking outperformed joint modeling and Cox landmarking when a complex relationship between the survival and longitudinal marker processes was present. It was also useful in application when there were several predictors for which the clinical relevance was unknown and multiple longitudinal biomarkers were present. Individualized dynamic predictions can be obtained from this method and the variable importance metric is useful for examining the changing predictive power of variables over time. In addition, RSF landmarking is easily implementable in standard software and using suggested specifications requires less computation time than joint modeling. CONCLUSIONS: RSF landmarking is a nonparametric, machine learning alternative to current methods for obtaining dynamic predictions when there are complex or unknown relationships present. It requires little upfront decision-making and has comparable predictive performance and has preferable computational speed.

Impact of acute kidney injury and nephrotoxic exposure on hospital length of stay.

OBJECTIVE: Acute kidney injury (AKI) is a common occurrence among hospitalized children and leads to increased mortality and prolonged length of stay (LOS) in critically ill patients. Few studies have examined the impact of AKI on LOS for common pediatric conditions. We hypothesized that a diagnosis of AKI would be associated with a longer hospital LOS and increased exposure to nephrotoxic medications for all patients. PATIENTS AND METHODS: We performed a multicenter retrospective cross-sectional analysis of 34 children's hospitals in the Pediatric Health Information System (PHIS) database from 1/2009 through 12/2013. Patients were grouped based on primary discharge diagnosis, number of days spent in an intensive care unit, and assignment of a secondary diagnostic code for AKI. Median LOS was compared among different patient groupings. Exposure to commonly used nephrotoxic medications was collected for each admission. RESULTS: A total of 588,884 admissions from 423,337 patients were included in the analysis. The median LOS among non-critically ill patients with and without AKI was 5 days [95% CI 3-10] versus 2 days [95% CI 1-4], respectively. Among critically ill patients, median LOS for those with and without AKI was 12 days [95% CI 7-20] versus 4 days [95% CI 2-7], respectively. Patients who developed AKI were more likely to have significant nephrotoxic exposure. CONCLUSIONS: Development of AKI was associated with longer hospital length of stay and increased nephrotoxic medication exposure for all diagnostic categories. Non-critically ill children with AKI were hospitalized the same length or longer than critically ill children without AKI.

A Pilot Study using the Compensatory Reserve Index to evaluate individuals with Postural Orthostatic Tachycardia syndrome.

PURPOSE: The diagnosis of Postural Orthostatic Tachycardia syndrome traditionally involves orthostatic vitals evaluation. The Compensatory Reserve Index is a non-invasive, FDA-cleared algorithm that analyses photoplethysmogram waveforms in real time to trend subtle waveform features associated with varying degrees of central volume loss, from normovolemia to decompensation. We hypothesised that patients who met physiologic criteria for Postural Orthostatic Tachycardia syndrome would have greater changes in Compensatory Reserve Index with orthostatic vitals. METHODS: Orthostatic vitals and Compensatory Reserve Index values were assessed in individuals previously diagnosed with Postural Orthostatic Tachycardia syndrome and healthy controls aged 12-21 years. Adolescents were grouped for comparison based on whether they met heart rate criteria for Postural Orthostatic Tachycardia syndrome (physiologic Postural Orthostatic Tachycardia syndrome). RESULTS: Sixty-one patients were included. Eighteen percent of patients with an existing Postural Orthostatic Tachycardia syndrome diagnosis met heart rate criteria, and these patients had significantly greater supine to standing change in Compensatory Reserve Index (0.67 vs. 0.51; p<0.001). The optimal change in Compensatory Reserve Index for physiologic Postural Orthostatic Tachycardia syndrome was 0.60. Patients with physiologic Postural Orthostatic Tachycardia syndrome were more likely to report previous diagnoses of anxiety or depression (p = 0.054, 0.042). CONCLUSION: An accurate diagnosis of Postural Orthostatic Tachycardia syndrome may be confounded by related comorbidities. Only 18% (8/44) of previously diagnosed Postural Orthostatic Tachycardia syndrome patients met heart rate criteria. Findings support the utility of objective physiologic measures, such as the Compensatory Reserve Index, to more accurately identify patients with true autonomic dysfunction.

Accuracy of parental perception of nighttime breathing in children with Down syndrome after adenotonsillectomy.

STUDY OBJECTIVES: Clinical practice guidelines recommend screening all children with Down syndrome for obstructive sleep apnea with polysomnography by age 4 years. Because persistent obstructive sleep apnea (obstructive apnea-hypopnea index > 1 event/h) following adenotonsillectomy (T&A) is common in children with Down syndrome, it is important to know whether clinicians can rely on parental assessment postoperatively. The primary objective is to identify accuracy of parental perception of nighttime breathing following T&A compared with preoperative assessment. METHODS: Patients with Down syndrome who underwent T&A along with polysomnography prior to and after the surgical procedure were included. Parents completed a 3-question pre- and postsurgery survey regarding nighttime symptoms. The responses were categorized into 3 groups: infrequent (< 3 nights/wk), sometimes (> 3 nights/wk but < 6 nights/wk), or frequent (≥ 6 nights/wk) on at least 1 question. The primary end point was identifying the accuracy of parental perception of nighttime breathing in children with Down syndrome following T&A. RESULTS: A total of 256 children met inclusion criteria, of which 117 (46%) were included. A total of 71 (68%) children had an obstructive apnea-hypopnea index > 5 events/h preoperatively compared with 55 (47%) postoperatively. There was no association between parents' perception of symptoms and obstructive sleep apnea categorization postoperatively (P > .05) or of parents' perception of symptoms improving and obstructive sleep apnea categorization improving postoperatively (P > .05). CONCLUSIONS: Despite previous experience, parents are unable to predict nighttime breathing patterns following a T&A. We recommend obtaining a polysomnogram rather than relying on parental assessment to determine whether a T&A has been successful. CITATION: Chabuz CA, Lackey TG, Pickett KL, Friedman NR. Accuracy of parental perception of nighttime breathing in children with Down syndrome after adenotonsillectomy. J Clin Sleep Med. 2024;20(2):237-243.

Residual OSA in Down syndrome: does body position matter?

STUDY OBJECTIVES: To examine children with Down syndrome with residual obstructive sleep apnea (OSA) to determine if they are more likely to have positional OSA. METHODS: A retrospective chart review of children with Down syndrome who underwent adenotonsillectomy at a single tertiary children's hospital was conducted. Children with Down syndrome who had a postoperative polysomnogram with obstructive apnea-hypopnea index (OAHI) > 1 event/h, following adenotonsillectomy with at least 60 minutes of total sleep time were included. Patients were categorized as mixed sleep (presence of ≥ 30 minutes of both nonsupine and supine sleep), nonsupine sleep, and supine sleep. Positional OSA was defined as an overall OAHI > 1 event/h and a supine OAHI to nonsupine OAHI ratio of ≥ 2. Group differences are tested via Kruskal-Wallis test for continuous variables and Fisher's exact tests for categorical. RESULTS: There were 165 children with Down syndrome who met inclusion criteria, of which 130 individuals had mixed sleep. Patients who predominately slept supine had a greater OAHI than mixed and nonsupine sleep (P = .002). Sixty (46%) of the mixed-sleep individuals had positional OSA, of which 29 (48%) had moderate/severe OSA. Sleeping off their backs converted 14 (48%) of these 29 children from moderate/severe OSA to mild OSA. CONCLUSIONS: Sleep physicians and otolaryngologists should be cognizant that the OAHI may be an underestimate if it does not include supine sleep. Positional therapy is a potential treatment option for children with residual OSA following adenotonsillectomy and warrants further investigation. CITATION: Lackey TG, Tholen K, Pickett K, Friedman N. Residual OSA in Down syndrome: does body position matter? J Clin Sleep Med. 2023;19(1):171-177.