A growth chart of brain function from infancy to adolescence based on EEG.

BACKGROUND: In children, objective, quantitative tools that determine functional neurodevelopment are scarce and rarely scalable for clinical use. Direct recordings of cortical activity using routinely acquired electroencephalography (EEG) offer reliable measures of brain function. METHODS: We developed and validated a measure of functional brain age (FBA) using a residual neural network-based interpretation of the paediatric EEG. In this cross-sectional study, we included 1056 children with typical development ranging in age from 1 month to 18 years. We analysed a 10- to 15-min segment of 18-channel EEG recorded during light sleep (N1 and N2 states). FINDINGS: The FBA had a weighted mean absolute error (wMAE) of 0.85 years (95% CI: 0.69-1.02; n = 1056). A two-channel version of the FBA had a wMAE of 1.51 years (95% CI: 1.30-1.73; n = 1056) and was validated on an independent set of EEG recordings (wMAE = 2.27 years, 95% CI: 1.90-2.65; n = 723). Group-level maturational delays were also detected in a small cohort of children with Trisomy 21 (Cohen's d = 0.36, p = 0.028). INTERPRETATION: A FBA, based on EEG, is an accurate, practical and scalable automated tool to track brain function maturation throughout childhood with accuracy comparable to widely used physical growth charts. FUNDING: This research was supported by the National Health and Medical Research Council, Australia, Helsinki University Diagnostic Center Research Funds, Finnish Academy, Finnish Paediatric Foundation, and Sigrid Juselius Foundation.

Conservative Airway Management Successful in Majority of Infants With Pierre-Robin Sequence at Queensland Children's Hospital: A Retrospective Review.

PURPOSE: Pierre-Robin Sequence (PRS) is a congenital abnormality characterized by micrognathia, glossoptosis, and variable severity upper airway obstruction. Clear management algorithms are lacking, particularly the indications for surgical versus nonsurgical intervention. The authors reviewed the management of these children in Queensland. METHODS: All children diagnosed with PRS at Queensland Children's Hospital from April 2014 to October 2019 were identified (n=45), and their charts were retrospectively reviewed. Three management patterns emerged: prone/lateral positioning, nasopharyngeal airway (NPA) use, and surgery (tracheostomy or mandibular distraction). RESULTS: Most children (n=30; 67%) were managed successfully nonsurgically with an NPA (median age of insertion 0.25 mo, median duration 5.0 mo). Of these, 12 patients (40%) also required supplemental oxygen. The median age of NPA cessation was 5.5 months, with oxygen therapy ceasing at a median 8.25 months, upon which no further support was required. The remaining majority (n=13; 29%) of children were managed without an NPA, using positioning alone (10/13; 77%) or positioning combined with supplemental oxygen (1/13), CPAP (1/13), or both adjunct measures (1/13). Only 2 patients underwent surgical intervention. Feeding supplementation using nasogastric tube was necessary in 78% of patients for a median duration of 4 months. Cleft palate co-existed in all but one patient. CONCLUSION: Management of upper airway obstruction in PRS children is variable between units. Over a 5-year period, 96% of children with PRS were successfully managed without surgical intervention at the Queensland Children's Hospital. These findings contrast with some other literature and may suggest that more careful consideration of surgical intervention in PRS patients is prudent.

Real-world utility of overnight oximetry for the screening of obstructive sleep apnea in children.

BACKGROUND: Obstructive sleep apnea (OSA) is a common problem in children and can result in developmental and cognitive complications if untreated. The gold-standard tool for diagnosis is polysomnography (PSG); however, it is an expensive and time-consuming test to undertake. Overnight oximetry has been suggested as a faster and cheaper initial test in comparison to PSG as it can be performed at home using limited, reusable equipment. AIM: This retrospective case control study aims to evaluate the effectiveness of a home oximetry service (implemented in response to extended waiting times for routine PSG) in reducing the time between patient referral and treatment. METHODS: Patients undergoing diagnostic sleep evaluation for suspected OSA who utilized the Queensland Children's Hospital screening home oximetry service in the first year since its inception in 2021 (n = 163) were compared to a historical group of patients who underwent PSG in 2018 (n = 311). Parameters compared between the two groups included time from sleep physician review to sleep test, ENT review, and definitive treatment in the form of adenotonsillectomy surgery (or CPAP initiation for those who had already undergone surgery). RESULTS: The time from sleep physician review and request of the sleep-related study to ENT surgical treatment was significantly reduced (187 days for the HITH oximetry group vs 359 days for the comparable PSG group; p-value <0.05), and time from sleep study request to the report of results was significantly lower for patients in the oximetry group compared to those in the PSG group (11 days vs 105 days; p-value <0.05). CONCLUSION: These results suggest that for children referred to a tertiary sleep center for possible obstructive sleep disordered breathing, a home oximetry service can be effective in assisting sleep evaluation and reducing the time to OSA treatment.

Monitoring of physiologic features and treatment aspects of children on home invasive mechanical ventilation.

Pediatric home invasive mechanical ventilation patients are a small but resource-intensive cohort, requiring close monitoring and multidisciplinary care. Patients are often dependent on their ventilator for life support, with any significant complications such as equipment failure, tracheostomy blockage, or accidental decannulation becoming potentially life-threatening if not identified quickly. This review discusses the indications and variations in practice worldwide, in terms of models of care, including home care provision, choice of equipment, and monitoring. With advances in technology, optimal monitoring strategies for home, continue to be debated: In-built ventilator alarms are often inadequately sensitive for pediatric patients, necessitating additional external monitoring devices to minimize risk. Pulse oximetry has been the preferred monitoring modality at home, though in some special circumstances such as congenital central hypoventilation syndrome, home carbon dioxide monitoring may be important to consider. Children should be under regular follow-up at specialist respiratory centers where clinical evaluation, nocturnal oximetry, and capnography monitoring and/or poly(somno)graphy and analysis of ventilator download data can be performed regularly to monitor progress. Recent exciting advances in technology, particularly in telemonitoring, which have potential to hugely benefit this complex group of patients are also discussed.

Optimization of time series features to estimate brain age in children from electroencephalography.

Functional brain age measures in children, derived from the electroencephalogram (EEG), offer direct and objective measures in assessing neurodevelopmental status. Here we explored the effectiveness of 32 preselected 'handcrafted' EEG features in predicting brain age in children. These features were benchmarked against a large library of highly comparative multivariate time series features (>7000 features). Results showed that age predictors based on handcrafted EEG features consistently outperformed a generic set of time series features. These findings suggest that optimization of brain age estimation in children benefits from careful preselection of EEG features that are related to age and neurodevelopmental trajectory. This approach shows potential for clinical translation in the future.Clinical Relevance-Handcrafted EEG features provide an accurate functional neurodevelopmental biomarker that tracks brain function maturity in children.

Longitudinal change in sleep, functional, and behavioural characteristics in a cohort of children with Down syndrome.

This paper describes the longitudinal change in sleep, functional, and behavioural characteristics in a cohort of children with Down syndrome, including the effect of sleep interventions in a subset. A prospective longitudinal cohort study was undertaken in children with Down syndrome aged 3-16 years comparing (1) children referred to a tertiary sleep medicine clinic who received sleep hygiene advice and an additional sleep treatment (DSref_I) with (2) children attending the same clinic who only received sleep hygiene advice (DSref_N) and (3) children recruited from the community who, were not receiving any treatment (DScomm). Data collected included demographic and medical history information, Child Sleep Habits Questionnaire-Abbreviated (CSHQ-A), Life-Habits Questionnaire (Life-H) and Child Behaviour Checklist (CBCL) at baseline and then 6-monthly for a total of 18 months. Any sleep interventions during this time were recorded. A total of 57 children were included (DSref_I, n = 16; DSref_N, n = 25; DScomm, n = 16). At recruitment, the median CSHQ-A total score was high (>41) in all three subgroups, but highest in the DSref_I subgroup (median [interquartile range] Dsref_I score 58 [53-66] versus DSref_N score 49 [43-53], p = 0.019). Although improved, 80% of participants in the DSref_I subgroup still had a CSHQ-A total score >41 at the last assessment point. The median total Life-H and total CBCL scores were not significantly different between groups at baseline and there was no significant time, group, or interaction effect seen through the study. Over an 18-month period, sleep problems were seen to persist in children with Down syndrome. Treatment resulted in only modest improvements in sleep.

Siblings' experiences of sleep disruption in families with a child with Down syndrome.

OBJECTIVE: Adverse effects of sleep disruption are identified in parents who live with a child with Down Syndrome (DS), yet there is no research on siblings' experiences. This study addresses this knowledge gap. DESIGN: A qualitative research study using semi-structured interviews to understand the experiences of siblings of a child with DS and sleep difficulties from the perspectives of parents and siblings. PARTICIPANTS: Eleven siblings aged 5-15 years old, and 11 parents, from 8 families with a child with DS in Australia. METHODS: Semi-structured sibling interviews explored what it was like to have a sibling with DS and sleep difficulties; the participant's own sleep; how their sleep affected how they felt during the day; how sleep impacted their family; and advice that they would give to other siblings. Parent interviews included similar topics; here we report on excerpts in which parents reference siblings. Interviews were audio recorded, transcribed verbatim, and analyzed using a reflexive thematic analysis. RESULTS: Siblings and parents acknowledge sleep disruption for siblings; yet sleep disruption is normalized, viewed with acceptance and inevitability. Siblings report adverse effects from sleep disruption, view sleep in a relational way, and cope with sleep disruption. Parents can underestimate siblings' sleep disruption and are uncertain whether siblings' symptoms result from sleep disruption or other causes. CONCLUSIONS: Siblings of a child with DS experience sleep disruption and may be at risk of developing long-term health problems without focused support.

Use of extended reality in sleep health, medicine, and research: a scoping review.

STUDY OBJECTIVES: This scoping review explores the use of extended reality (virtual, augmented, and mixed reality) within sleep health, sleep medicine, and sleep research. It aims to provide insight into current uses and implementation considerations whilst highlighting directions for future research. METHODS: A systematic scoping review was undertaken informed by the preferred reporting items for systematic reviews and meta-analyses for scoping reviews and Johanna Briggs Institute. RESULTS: The use of virtual reality (VR) as a research tool in the investigation of areas such as dreaming and memory reactivation is growing. Thirty-one articles were identified in total with 20 utilizing VR to improve sleep as a clinical intervention. CONCLUSIONS: Research exploring the utility of VR as a clinical intervention in various patient populations and clinical settings is therefore warranted. Researchers and clinicians should ensure that extended reality interventions are developed based on clinical reasoning and informed by evidence of both sleep medicine and the effects of virtual and augmented reality. Where possible future research should utilize up-to-date technology and reporting frameworks to assist in the translation of research into clinical practice.

Extended Reality Use in Paediatric Intensive Care: A Scoping Review.

Background: Extended reality (XR) technology such as virtual and augmented reality is increasingly being utilised in paediatric medicine due to its role in medical education and reported positive impacts on outcomes including pain, anxiety, and sleep. To the author's knowledge, no previous reviews investigating the use of XR in paediatric intensive care have been undertaken. Objectives: To scope the use of XR in paediatric intensive care, and assess its barriers to adoption, including safety considerations, cleaning and infection control. Eligibility criteria: All articles of any methodological design discussing the use of XR within paediatric intensive and critical care were included. Sources of evidence: Four databases (EMBASE, CINAHL, PsychInfo, PubMed) and Google Scholar were searched without any limitations on publication year. Charting methods: Data was extracted into Microsoft Excel by two authors independently (AG & SF) and cross-checked for completeness. Results: One hundred and eighty-eight articles were originally identified. Following the application of eligibility criteria 16 articles utilising XR in clinical interventions (n = 7) and medical education (n = 9) were included. Articles utilised VR and AR for highly variable purposes within both medical education (eg disaster preparedness, intubation) and clinical interventions (eg decrease pain, nausea, anxiety and improve Glasgow Coma Scale). Conclusions: While research into the use of XR in paediatric intensive care is still in its infancy it has increased dramatically over the past 5 years within two key areas. Firstly, in healthcare education, to assist in the acquisition of PICU-specific knowledge and practice of skills such as intubation of difficult airways. Secondly, studies have evaluated and demonstrated that with appropriate use, VR appears to be a safe and feasible intervention to decrease pain and anxiety in PICU patients.

The management of residual OSA post-adenotonsillectomy in children with down syndrome: The experience of a large tertiary sleep service.

INTRODUCTION: Obstructive Sleep Apnoea (OSA) is common in children with Down Syndrome (DS). Adenotonsillectomy is regarded as first line treatment for OSA but does not always lead to resolution of symptoms in this group of children. Management of residual OSA is variable with no existing recommendations to guide clinical practice. AIM: To describe the experience of a large tertiary sleep service in managing residual OSA in children with DS following upper airway surgery (adenotonsillectomy, adenoidectomy or tonsillectomy). METHODS: A retrospective study of children who were under evaluation at the Queensland Children's Hospital sleep medicine department between October 2013 to April 2022 for residual OSA, after upper airway surgery was undertaken. RESULTS: 148 children with DS who underwent polysomnography for evaluation of OSA were identified. 100 were included in this study and of these, 77 underwent adenotonsillectomy, 19 adenoidectomy, and 4 tonsillectomy. Post-surgical PSG data of all 100 children showed residual mixed sleep disordered breathing in 68 children. 41 were recommended CPAP following surgery, while 21 underwent further surgery. CONCLUSIONS: Residual OSA was confirmed to be highly prevalent in children with DS who had already undergone upper airway surgery for OSA. This study identified that CPAP is possible to establish in most children with DS and can be used to manage residual OSA in this population. Approximately one-third of this group were able to discontinue therapy at a median duration of 18 months, suggesting resolution of disease with time can occur in some children.

Tolerance of polysomnography in children with neurodevelopmental disorders compared to neurotypical peers.

STUDY OBJECTIVES: Diagnostic polysomnography (PSG) is the gold standard test to evaluate sleep-disordered breathing in children. Little is known about how children with neurodevelopmental disorders (NDD) tolerate electrodes and sensors in PSG compared to neurotypical children. METHODS: In this retrospective cohort study of children > 12 months of age who underwent diagnostic PSG at our center from 01/01/2021-30/06/2021, we used sleep technician and physician reports to determine how PSG was tolerated in children with NDD compared to neurotypical children. Subanalyses included tolerance of individual electrodes and sensors and subgroups of NDD (eg, Trisomy 21). RESULTS: A total of 132 children with a NDD and 139 neurotypical children underwent diagnostic PSG. The median age of all children was 8 years, 39% were female, and 50% had a sleep disorder identified on PSG, with no significant differences between NDD and neurotypical groups. The most poorly tolerated sensors for all children were the nasal prongs (poorly tolerated in 30% of all children), followed by thermistor (14%) and electroencephalography electrodes (6%). Children with NDD were > 3 times more likely (odds ratio 3.1, 95% confidence interval 1.8-5.3) to experience problems tolerating any study leads than neurotypical children. Subgroup analysis revealed children with Trisomy 21 had the greatest difficulty tolerating PSG set-up and leads. CONCLUSIONS: This retrospective study demonstrates that children with neurodevelopmental disorders are less likely to tolerate PSG monitoring than neurotypical children and highlights the need to develop alternative measures for evaluation of sleep disorders in this population. CITATION: Lanzlinger D, Kevat A, Collaro A, Poh SH, Pérez WP, Chawla J. Tolerance of polysomnography in children with neurodevelopmental disorders compared to neurotypical peers. J Clin Sleep Med. 2023;19(9):1625-1631.

Communicating the complex lives of families that include a child with Down syndrome.

Families of children with Down syndrome experience complex lives and needs, yet the few existing studies on these families are written in conventional academic prose that is not optimal for knowledge translation beyond academia, particularly for busy healthcare professionals. In this paper, we Depart Radically in Academic Writing (DRAW) (Mackinlay, 2022) and present data poetry and two case studies that draw upon semi-structured interviews with mothers, fathers, and siblings, who were interviewed separately about their experiences of having a child/sibling with Down syndrome. We introduce our interdisciplinary team that includes academics and clinicians to contextualise our focus on research translation. We demonstrate that writing with creative criticality (i.e. 'DRAWing') contributes an embodied and affective understanding of research participants' stories, which is largely lacking in the academic literature on families of children with Down syndrome and the sociology of health and illness field more broadly. Moreover, DRAWing can impact audiences emotionally as well as intellectually (Richardson, 2003, p. 924), which has important knowledge translation implications for both healthcare professionals and these families. DRAWing can capture healthcare professionals' attention, prompting them to critically reflect on their practices and opportunities for improving care and treatment for these families.

Parents' Experiences of Having a Child with Down Syndrome and Sleep Difficulties.

OBJECTIVES: Sleep disorders are prevalent in children with Down Syndrome (DS). However, sleep treatment is not always readily accessed by this group. This study aims to understand families' experiences of having a child with DS and sleep difficulties, and in particular, their healthcare experiences, with the goal of informing practice improvements. METHODS: We conducted semi-structured interviews with 34 parents (fathers n = 4 and mothers n = 30) with open-ended questions about parents' experiences of sleep, family dynamics, and healthcare. We operationalized a reflexive Thematic Analysis. RESULTS: Parents normalized their experiences of having a child with DS and sleep problems. Parents acknowledged that sleep disruption has adverse and pervasive impacts on their wellbeing and family dynamics, but also found this difficult to identify as a health problem. They accepted sleep difficulties as a regular part of bringing up any child, particularly one with a disability. When they did seek treatment for their child's sleep difficulties, parents often reported encountering insensitive and inadequate care and described that, at times, healthcare professionals also normalized children's sleep difficulties, resulting in sub-optimal treatment. This included at times failure to refer to tertiary sleep medicine services when required. CONCLUSIONS: Parents' and healthcare professionals' normalization of sleeping difficulties denies that they are both deleterious and modifiable. Practice implications include raising healthcare professionals' awareness of the importance of proactively addressing sleep, with sensitivity to families' normalization strategies, recognizing that families may require prompting to report concerns.

Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea.

STUDY OBJECTIVES: Adenotonsillectomy (AT) forms part of first-line management for pediatric obstructive sleep apnea. In nonrandomized studies of preschool-aged children, postoperative weight gain has been seen following AT, raising concerns regarding later obesity. Using longitudinal data from a multicenter randomized controlled trial, we assessed the impact of AT on growth trajectories in preschool-aged children with mild-moderate obstructive sleep apnea. METHODS: A total of 190 children (aged 3-5 years) with obstructive apnea-hypopnea index ≤ 10 events/h were randomly assigned to early (within 2 months) or routine (12-month wait) AT. Anthropometry and polysomnography were performed at baseline, 12-month, and 24-month time points for 126 children. Baseline characteristics were compared using a Mann-Whitney or t test for continuous variables and Fisher's exact test for categorical variables. Longitudinal data underwent linear mixed modeling. RESULTS: For body mass index (BMI) z-score there was a significant increase in the early surgery group between 0 and 12 months (0.4, 95% confidence interval 0.1-0.8) but not from 12-24 months. For the routine surgery group there was an identical significant BMI z-score increase in the first 12 months following surgery, ie, between 12- and 24-month time points (0.45, 95% confidence interval 0.1-0.8) but not from 0-12 months (preoperative time). Final BMI z-score was similar between groups. Findings for weight-for-age z-score were similar to the findings for BMI z-score. Height-for-age z-score was not significantly different between different time points or intervention groups. CONCLUSIONS: This study provides randomized controlled trial evidence of notable, but time-limited, increase in the BMI and weight of preschool children with mild-moderate obstructive sleep apnea in the months immediately following AT. CLINICAL TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Registry; Name: POSTA Child Study (Preschool Obstructive Sleep Apnea Tonsillectomy Adenoidectomy Study); URL: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336273&isReview=true; Identifier: ACTRN12611000021976. CITATION: Kevat A, Bernard A, Harris M-A, et al. Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea. J Clin Sleep Med. 2023;19(1):55-62.

Determining reference data for overnight oximetry in neonates: A pilot study.

OBJECTIVE: To determine the variability of overnight oximetry parameters in a group of normal, healthy term infants; to enable the calculation of the number of subjects required to produce reliable reference ranges for neonatal overnight oximetry. METHODS: A convenience sample of normal, healthy term neonates was recruited. Each had overnight oximetry using the Masimo SET Radical oximeter (data downloaded using Profox software). The report included the number of oxygen desaturation events (an absolute decrease in SpO2 of 4 or more), and the duration of oxygen saturations <90%. RESULTS: 21 babies were recruited with data available from 19. 32% were female; 68% born by vaginal delivery; 37% fully breast feeding, 53% bottle and 11% by a combination of both. The mean (SD) GA was 39.2 (0.79) weeks, the mean (SD) BW was 3477 (240) grams. The median (IQR) post-natal age at the time the oximetry recording started was 31 (28-41) hours; four babies were <24 h old. All babies had some desaturation events ranging from 4 to 36 times per hour. On average babies spent 3.0% (SD 2.3) of the time with an SpO2 < 90% (range 0.12-7.94). CONCLUSIONS: In a cohort of healthy term neonates, as assessed by overnight oximetry, the mean SpO2 was 97% (SD 1, range 95-99). All neonates had a number of oxygen desaturation events ranging from 4 to 36 per hour. The mean proportion of time spent with oxygen saturations below 90% was around 3%.

Management of residual OSA post adenotonsillectomy in children with Down Syndrome: A systematic review.

STUDY OBJECTIVE: The aim of this systematic review is to summarise the existing literature regarding management of residual obstructive sleep apnoea post adenotonsillectomy in children with Down Syndrome. METHODS: PubMed, EMBASE, Cochrane and Scopus were searched to retrieve all studies published up to May 2020 regarding the management of obstructive sleep apnoea in children with Down Syndrome post adenotonsillectomy. RESULTS: Eight studies were identified including five retrospective studies, two prospective and one case series. Five articles addressed surgical treatments only, two articles addressed hypoglossal nerve stimulation and one article addressed both surgical and medical treatments. Findings were similar across most studies where the obstructive apnoea hypopnoea index (oAHI) was reduced post intervention however given the heterogeneity in methodology and patient demographics, results were not directly comparable. Limited evidence was found regarding BMI and outcome post-surgery, suggesting that those who were normal weight or overweight had a significant reduction in the oAHI, compared to those who were obese. CONCLUSION: The most optimal treatment for the management of residual obstructive sleep apnoea remains uncertain. There are various treatment options described in the literature, however, they have not been thoroughly studied, with only eight relevant articles found. Studies comparing outcomes following different treatment interventions and using consistent parameters are required to gain further understanding of the most optimal treatment for residual obstructive sleep apnoea in this population. Understanding if specific phenotypic features, such as weight, influence response to therapy will also be important. This information will help to develop treatment algorithms, which will assist in improving patient care by directing treatment and ensuring a more consistent approach to overall management. The high prevalence of residual obstructive sleep apnoea in children with Down Syndrome following first line treatment makes this a clinically important area to target in this particular cohort of children to avoid long term complications of untreated OSA.

Sleep, Function, Behaviour and Cognition in a Cohort of Children with Down Syndrome.

OBJECTIVE: To describe the sleep problems experienced by children with Down syndrome attending a tertiary sleep clinic and relationship with behaviour, function and cognition. METHODS: Data were collected from children with Down syndrome aged 3-18 years old. Carers completed the Abbreviated Child Sleep Habits Questionnaire, Child Behaviour Checklist and Life-Habits Questionnaire at enrolment. Cognitive assessment (Stanford-Binet 5) was undertaken by a trained psychologist. Children received management for their sleep problem as clinically indicated. RESULTS: Forty-two subjects with a median age of 6.8 years (Interquartile Range-IQR 4.5, 9.8) were enrolled. A total of 92% were referred with snoring or symptoms of Obstructive Sleep Apnoea (OSA), with 79% of those referred having had previous ENT surgery. Thus, 85% of all participants underwent a sleep study and 61% were diagnosed with OSA (OAHI ≥ 1/h). Based on questionnaires, 86% of respondents indicated that their child had a significant sleep disorder and non-respiratory sleep problems were common. Non-respiratory problems included: trouble going to sleep independently (45%), restless sleep (76%), night-time waking (24%) and bedtime resistance (22%). No significant correlations were found between sleep measures (behavioural and medical sleep problems) and the behavioural, functional or cognitive parameters. CONCLUSION: Sleep disorders were very common, especially non-respiratory sleep problems. OSA was common despite previous surgery. No association was found between sleep-related problems (snoring, sleep-study-confirmed OSA or non-respiratory sleep problem) and parent-reported behavioural problems, functional impairments or intellectual performance. This may reflect limitations of the measures used in this study, that in this population ongoing problems with daytime function are not sleep related or that a cross-sectional assessment does not adequately take into account the impacts of past disease/treatments. Further research is required to further evaluate the tools used to evaluate sleep disorders, the impact of those disorder on children with Down syndrome and interventions which improve both sleep and daytime function.

Ventilatory support at home for children: A joint position paper from the Thoracic Society of Australia and New Zealand/Australasian Sleep Association.

The goal of this position paper on ventilatory support at home for children is to provide expert consensus from Australia and New Zealand on optimal care for children requiring ventilatory support at home, both non-invasive and invasive. It was compiled by members of the Thoracic Society of Australia and New Zealand (TSANZ) and the Australasian Sleep Association (ASA). This document provides recommendations to support the development of improved services for Australian and New Zealand children who require long-term ventilatory support. Issues relevant to providers of equipment and areas of research need are highlighted.

Sleep and Behavior 24 Months After Early Tonsillectomy for Mild OSA: An RCT.

BACKGROUND AND OBJECTIVES: The Preschool Obstructive Sleep Apnea Tonsillectomy and Adenoidectomy study is a prospective randomized controlled study of children aged 3 to 5 years. This follow-up evaluated postoperative outcomes 24 months after randomization. METHODS: Baseline, 12-month, and 24-month assessments included intellectual ability, polysomnography, audiology, a pediatric sleep questionnaire, the parent rating scale of the Behavior Assessment System for Children, and the Behavior Rating Inventory of Executive Functioning. RESULTS: In total, 117 (55% male) of 190 children, 61.6% of those initially randomly assigned, attended 24-month follow-up; 62 of 99 were assigned T/A within 2 months (eT/A); and 55 of 91 were assigned to T/A after the 12-month follow-up (T/A12). Intellectual ability, our primary outcome, did not differ according to the timing of T/A. Exploratory analyses revealed changes in both groups after T/A, including fewer children having day sleeps (eT/A from baseline 97% to 11%, T/A12 from 36% at 12 months to 9%), improved symptom scores (eT/A 0.62 to 0.25, T/A12 0.61 to 0.26; P < .001), improved behavior T-scores (eT/A 71.0 to 59.9, T/A12 63.6 to 50.5; P < .001), and improved polysomnography (obstructive apnea-hypopnea index eT/A 1.9 to 0.3 per hour, T/A12 1.3 to 0.3; P < .001). The eT/A group revealed temporary postoperative improvement of Woodcock-Johnson III subscales (sound blending and incomplete word scores) and behavioral withdrawal. CONCLUSIONS: T/A for mild obstructive sleep apnea led to large improvements in sleep and behavior in preschool-aged children, regardless of the timing of surgery.

Predictors of home oxygen duration in chronic neonatal lung disease.

AIMS: In infants with chronic neonatal lung disease (CNLD), we aimed to identify predictors of home oxygen duration, predictors of discharge oxygen flow rates, and the association of oxygen flow rates with respiratory outcomes. METHODS: Infants with CNLD requiring home oxygen in 2016 and 2017 were retrospectively reviewed. Hazard ratios (HR) were estimated from Cox proportional hazards regression models in the cohort. A multinomial logistic regression model examined the effects of maternal and infant variables on discharge oxygen flow rates. Kruskal-Wallis test with univariate linear regression and Fisher's exact test with binomial univariate logistic regression were used to examine associations between oxygen flow groups and post-discharge clinical variables. RESULTS: One hundred and forty-nine infants were included. Median corrected gestational age (CGA) at oxygen cessation was 6.8 months (interquartile range, 4.4) with 87.2% of infants weaned by 12 months CGA. Shorter initial neonatal intensive care unit (NICU) stay predicted faster oxygen weaning at 9 months (HR, 0.99; 95% confidence interval [CI], 0.98-1.00, p = .02) and 12 months (HR, 0.99; 95% CI, 0.98-1.00, p = .02). Infants with hypercarbia at discharge or discharged from NICU at higher CGA had higher odds of requiring ≥ 200 ml/min relative to ≤ 125 ml/min oxygen. Infants discharged with > 250 ml/min oxygen were more likely to have a respiratory-related admission before 2 years chronological age. CONCLUSION: Shorter initial NICU stay was the best predictor of earlier home oxygen cessation. At NICU discharge, infants with hypercarbia or a higher CGA may require more home oxygen and experience more respiratory-related hospital admission in the first 2 years of chronological age.