Neurobehavioral functioning in adolescents with and without obesity and obstructive sleep apnea.

STUDY OBJECTIVES: Children and adults with obstructive sleep apnea syndrome (OSAS) exhibit neurobehavioral abnormalities, but few studies have evaluated the transitional stage of adolescence. Obesity is also associated with neurobehavioral abnormalities, and many patients with OSAS are obese. However, the confounding effect of obesity on neurobehavioral abnormalities in adolescents with OSAS has not been evaluated. We hypothesized that obese adolescents with OSAS would exhibit more neurobehavioral abnormalities than obese and lean adolescents without OSAS. DESIGN: Cross-sectional, case control. SETTING: Sleep Center and community. PARTICIPANTS: Obese adolescents with OSAS compared to (1) nonsnoring, obese controls without OSAS, and (2) nonobese, nonsnoring controls. INTERVENTIONS: Neurobehavioral evaluation. MEASUREMENTS AND RESULTS: Obese adolescents with OSAS had significantly worse executive function and attention compared to both obese (P < 0.001) and lean (P < 0.001) controls, and more depression (P = 0.004) and externalizing symptoms than lean controls (P = 0.008). A higher percentage of participants in the OSAS group scored in the clinically abnormal range on executive functioning, attention, sleepiness, and behavioral functioning than lean controls. Mediation analyses indicated that level of sleep apnea significantly mediated the effect of body mass on executive functioning, attention, and behavior. CONCLUSIONS: Obese adolescents with OSAS show impaired executive and behavioral function compared to obese and lean controls, and are more likely to score in the clinically abnormal range on measures of neurobehavioral functioning. These results are especially concerning given that the frontal lobe is still developing during this critical age period. We speculate that untreated OSAS during adolescence may lead to significant neurobehavioral deficits in adulthood.

Prevalence of periodic limb movements during sleep in normal children.

STUDY OBJECTIVES: Although the American Academy of Sleep Medicine (AASM) mandates that periodic limb movements during sleep (PLMS) be scored on every polysomnogram, and considers a periodic limb movement index (PLMI) > 5/h abnormal in children, there is a lack of community-derived data regarding the prevalence of PLMS in children, and no data to support this cutoff value. Therefore, the aim of this study was to determine the prevalence of PLMS in a sample of normal children. DESIGN: Retrospective study. PARTICIPANTS: 195 healthy, non-snoring children aged 5-17 years, recruited from the community, who underwent polysomnography for research purposes. METHODS: PLMS were scored using the AASM 2007 criteria. MEASUREMENTS AND RESULTS: The group age (median [IQR]) was 12.9 [10-15] years, and 58% were male. Sleep architecture was normal, and the obstructive apnea hypopnea index was 0.1 [0-0.3]/h. The median PLMI was 0/h, ranging from 0 to 35.5/h. Fifteen (7.7%) subjects had a PLMI > 5/h, and only 3 (1.5%) met the adult pathologic criterion of more than 15/h. Use of the 95th percentile PLMI cutoff of 7.2/h produced little difference in categorization between groups. Children with a PLMI > 5/h had a higher arousal index than those with a lower PLMI (11.6 [8.8-14.6] vs 8.1 [6.1-9.9]/h, respectively, P = 0.003). CONCLUSIONS: This study provides normative data to the field and supports the clinical periodic limb movement index cutoff of > 5/h based on both prevalence and the correlate of increased sleep fragmentation. Periodic limb movements during sleep are infrequent in normal children recruited from the community. CITATION: Marcus CL, Traylor J, Gallagher PR, Brooks LJ, Huang J, Koren D, Katz L, Mason TB, Tapia IE. Prevalence of periodic limb movements during sleep in normal children.

Prediabetic obese adolescents have a more atherogenic lipoprotein profile compared with normoglycemic obese peers.

OBJECTIVE: To compare lipoprotein profiles of prediabetic to normoglycemic obese adolescents. STUDY DESIGN: Cross-sectional study of 95 obese, pubertal adolescents (12-17 years), who underwent oral glucose tolerance test, lipid panel, and lipoprotein subclass particle analysis (nuclear magnetic resonance spectroscopy). Univariate and linear regression analyses compared prediabetic and normoglycemic groups. RESULTS: Of 95 obese adolescents enrolled in the study, 22.1% (n = 21) had prediabetes. They were similar to normoglycemic adolescents (n = 74) in age, race, body mass index, standard lipids, total low-density lipoprotein particles (LDL-P), and total high-density lipoprotein particles (HDL-P). However, prediabetics had higher concentrations of small LDL-P (714.0 ± 288.0 vs 537.7 ± 266.5 nmol/L, P = .01) and smaller LDL-P size (20.73 ± 0.41 vs 21.18 ± 0.65 nm, P = .003), than normoglycemic youth. Prediabetics had higher small HDL-P (18.5 ± 3.8 vs 16.6 ± 3.9 umol/L, P = .046), lower large HDL-P (4.49 ± 2.0 vs 6.32 ± 2.6 umol/L, P = .004), and smaller HDL-P size (8.73 ± 0.31 vs 9.01 ± 0.39 nm, P = .003). After adjusting for demographics, Tanner stage, and body mass index using multiple linear regression, all differences remained significant except for small HDL-P. After additional adjustment for Homeostasis Model Assessment-Insulin Resistance Index, only LDL-P size difference remained significant. CONCLUSION: Obese prediabetic adolescents have a significantly more atherogenic lipoprotein profile compared with obese normoglycemic peers. Prediabetic adolescents may benefit from more aggressive interventions to decrease future cardiovascular risk.

Postoperative surveillance and detection of postprandial hypoglycemia after fundoplasty in children.

OBJECTIVE: To evaluate the prevalence of postprandial hypoglycemia (PPH) after fundoplasty after the initiation of a universal postoperative glucose surveillance plan in the neonatal intensive care unit (NICU). STUDY DESIGN: This was a retrospective chart review of children (newborn to 18 years) who underwent fundoplasty at The Children's Hospital of Philadelphia during the 2-year-period after the launch of a surveillance protocol in the NICU and other units. The rate of screening, frequency of PPH (postprandial blood glucose <60 mg/dL [3.3 mmol/L] on 2 occasions), frequency of postprandial hyperglycemia preceding PPH, timing of PPH presentation, and related symptoms were evaluated. RESULTS: A total of 285 children were included (n = 64 in the NICU; n = 221 in other units). Of the children screened in all units, 24.0% showed evidence of PPH, compared with 1.3% of unscreened children. Hyperglycemia preceded PPH in 67.7% (21/31) of all screened children. Within the NICU, most children had PPH within 1 week, but only 53.3% exhibited symptoms of dumping syndrome. CONCLUSIONS: This study supports the use of universal postoperative blood glucose surveillance in identifying PPH in children after fundoplasty. Earlier identification of PPH would lead to earlier treatment and minimize the effects of unidentified hypoglycemic events.

Assessment of neonatal electroencephalography (EEG) background by conventional and two amplitude-integrated EEG classification systems.

OBJECTIVE: To determine the agreement among conventional electroencephalography (CEEG) terminology background classification and a simple and an advanced amplitude-integrated EEG (aEEG) system, and to evaluate whether aEEG interpreter experience or electrographic seizures affect this agreement. STUDY DESIGN: CEEG background was classified by traditional interpretive criteria for 144 neonatal recordings, from which a single channel was converted to aEEGs. These aEEGs were independently interpreted by neonatologists according to the simple and advanced classification systems. RESULTS: Interreader agreement was better with the simple aEEG system compared with the advanced aEEG system (multirater kappa, 0.66 vs 0.44). Fair-to-moderate agreement was found between both of the aEEG classification systems and CEEG (simple: kappa, 0.34 to 0.45; advanced: kappa, 0.36 to 0.45). Agreement did not vary significantly based on the aEEG interpreter experience or the presence of seizures. CONCLUSIONS: Neonatologists found better agreement using the simple aEEG system regardless of their expertise or the presence of seizures. This finding has implications for patient selection in future multicenter neonatal neuroprotection studies.

Cytokine elaboration in critically ill infants with bacterial sepsis, necrotizing entercolitis, or sepsis syndrome: correlation with clinical parameters of inflammation and mortality.

OBJECTIVE: To test the hypothesis that cytokines might distinguish critically ill infants with bacterial sepsis or necrotizing enterocolitis (NEC) from those with sepsis syndrome and that these elevations would be correlated with clinical variables of inflammation and mortality. STUDY DESIGN: We measured plasma and tracheal aspirate (TA) levels of interleukin-8 (IL-8), epithelial neutrophil activating peptide (ENA-78), IL-10, and IL-18 in 84 neonates with suspected sepsis or NEC. Thirty-one infants had bacterial sepsis, 19 had NEC, and 34 infants with negative results on cultures had sepsis syndrome. RESULTS: Plasma IL-8 and IL-10 levels were significantly increased in infants with bacterial sepsis compared with those in infants with sepsis syndrome. Plasma IL-8, ENA-78, and IL-10 levels were elevated in infants with NEC compared with those in infants with sepsis syndrome. TA IL-8 and IL-10 levels were also increased in infants with bacterial sepsis; TA ENA-78, and IL-18 were not elevated in infants with sepsis or NEC when compared with infants with sepsis syndrome. Plasma and TA cytokine levels correlated with hematologic parameters. Plasma cytokine levels were higher in infants who did not survive than in infants who did survive. CONCLUSIONS: Plasma and TA cytokine levels are elevated in critically ill infants with bacterial sepsis or NEC compared with those in infants with sepsis syndrome. Our results suggest distinct patterns of cytokine elaboration in different disease states.