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1.
Laryngoscope ; 2019 Nov 29.
Artigo em Inglês | MEDLINE | ID: mdl-31782808

RESUMO

OBJECTIVE: The Clinical Assessment Score-15 (CAS-15) has been validated as an office-based assessment for pediatric sleep-disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS-15 in a multi-institutional fashion. METHODS: Five hundred and thirty children from 13 sites with suspected sleep-disordered breathing were recruited, and the investigators completed the CAS-15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty-seven subjects had a follow-up CAS-15. RESULTS: Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation [SD]) CAS-15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS-15 and the initial apnea-hypopnea index (AHI) was 0.41 (95% confidence interval [CI], 0.29, 0.51), n = 212, P < .001. A receiver-operating characteristic curve predicting positive polysomnography (AHI > 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P < .001, effect size = 3.1. CONCLUSION: This study establishes the generalizability of the CAS-15 as a useful office tool for the evaluation of pediatric sleep-disordered breathing. LEVEL OF EVIDENCE: 2B Laryngoscope, 2019.

2.
Cleft Palate Craniofac J ; 56(7): 890-895, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31282194

RESUMO

OBJECTIVE: To determine whether nonsupine sleep improves obstructive sleep apnea (OSA) in infants with cleft palate undergoing polysomnography (PSG). DESIGN: Retrospective chart review. SETTING: Tertiary care pediatric hospital. PATIENTS: Twenty-seven infants (1 month to 1 year) with cleft palate with or without cleft lip (CP ± L) undergoing PSG testing for suspected OSA were included. MAIN OUTCOME MEASURES: Polysomnography measures included obstructive apnea-hypopnea index (OAHI), central apnea-hypopnea index (CAHI), oxygen saturation (SpO2) nadir, SpO2, and end-tidal carbon dioxide (ETCO2). RESULTS: Twenty-three PSGs with at least 20 minutes of sleep in both the supine and the nonsupine positions were analyzed. The supine OAHI (mean: 16.8 events/hour; standard deviation [SD]: 18.5) and nonsupine OAHI (mean: 12.6 events/hour; SD: 12.6) did not differ significantly (P = .10). The supine CAHI (mean: 1.9 events/hour; SD: 2.7) and nonsupine CAHI (mean: 3.1 events/hour; SD: 3.7; P = .15), the supine SpO2 nadir (mean: 81.2%; SD: 6.3) and nonsupine SpO2 nadir (mean: 81.8%; SD: 5.3; P = .70), the supine mean SpO2 (mean: 95.5%; SD: 1.9) and nonsupine mean SpO2 saturation (mean: 95.3%; SD: 2.4; P = .34), and the supine ETCO2 (mean: 45.4 mm Hg; SD: 5.3) and nonsupine ETCO2 (mean: 42.5 mm Hg; SD: 10.1; P = .24) were also similar. CONCLUSIONS: There were no significant improvements in OSA metrics during nonsupine sleep in infants with CP ± L. Prior to recommending nonsupine positioning which increases infant's exposure to sudden infant death syndrome risk, we advocate obtaining a PSG to verify an objective improvement in OSA.

3.
Otolaryngol Head Neck Surg ; 161(3): 529-535, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31035864

RESUMO

OBJECTIVE: To assess the current practice patterns of pediatric otolaryngologists in managing obstructive sleep-disordered breathing 6 years following the 2011 publication of the clinical practice guideline "Polysomnography for Sleep-Disordered Breathing prior to Tonsillectomy in Children." STUDY DESIGN: Cross-sectional survey. SETTING: American Society of Pediatric Otolaryngology (ASPO) members. SUBJECTS AND METHODS: An electronic survey to assess ASPO members' adherence to polysomnography guidelines prior to tonsillectomy. RESULTS: Forty percent (170 of 427) of ASPO members completed the survey, with 73% in academic practice and 27% in private practice. Snoring represented, on average, 48% of the respondents' practices. The percentage of respondents who requested a polysomnogram prior to tonsillectomy ≥90% of the time was 55% (n = 94) for Down syndrome, 41% (n = 69) for a child <2 years old, and 29% (n = 49) for obese children. A total of 109 (73%) and 112 (75%) respondents admit at least 90% of the time for a child with Down syndrome and for a child <3 years of age, respectively, but only 52 (35%) have a similar practice for an obese child. Only 37% adhere to the inpatient admission recommendation for children with documented obstructive sleep apnea on polysomnogram. CONCLUSION: The current polysomnogram practice patterns for responding pediatric otolaryngologists are not aligned with the clinical practice guideline of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. The threshold for overnight observation when a preoperative polysomnogram has not been performed may be too low. A campaign is necessary to educate clinicians who take care of children with obstructive sleep-disordered breathing and to obtain more evidence to further define best practice.


Assuntos
Otolaringologia , Pediatria , Polissonografia , Padrões de Prática Médica , Apneia Obstrutiva do Sono/diagnóstico , Pré-Escolar , Estudos Transversais , Humanos , Lactente
4.
J Pediatr ; 211: 179-184.e1, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31084917

RESUMO

OBJECTIVES: To examine weight changes relative to surgical success in children with Down syndrome and obstructive sleep apnea (OSA). STUDY DESIGN: Retrospective chart review of children with Down syndrome undergoing tonsillectomy from 2005 to 2016 for OSA at a tertiary care children's hospital. Only patients with pre-and postoperative polysomnogram within 6 months of tonsillectomy were included. Demographics, weight, height, and polysomnogram data were collected. Body mass index (BMI), expressed as a percentage of the 95th percentile (%BMIp95), was calculated for 24 months prior to and following surgery. Pre-and postoperative OSA severity were also recorded. The postoperative obstructive/hypopnea index identified subjects with resolution of obstruction (obstructive/hypopnea index <2 events/hour) or persistent mild/moderate/severe obstructive apnea. Regression analyses were used to compare %BMIp95 pre- and post-tonsillectomy with %BMIp95 by OSA status following tonsillectomy. RESULTS: A total of 78 patients with Down syndrome whose mean age was 5.29 years at time of tonsillectomy were identified. There was no difference between best-fit curves of %BMI p95 pre-and post-tonsillectomy. There was no difference between best-fit curves of %BMI p95 in patients who saw resolution of OSA after tonsillectomy vs patients with residual OSA. CONCLUSIONS: Tonsillectomy neither alters the BMI trajectory of children with Down syndrome, nor changes differentially the risk for obesity in children whose OSA did or did not resolve after surgery.

5.
Otolaryngol Head Neck Surg ; 160(2): 187-205, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30921525

RESUMO

OBJECTIVE: This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age, based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE: The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS: The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of obstructive sleep-disordered breathing. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE: Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. Inclusion of 2 consumer advocates on the guideline update group. Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). Addition of an algorithm outlining KASs. Enhanced emphasis on patient and/or caregiver education and shared decision making.


Assuntos
Adenoidectomia/normas , Guias de Prática Clínica como Assunto , Melhoria de Qualidade , Apneia Obstrutiva do Sono/etiologia , Tonsilectomia/normas , Tonsilite/complicações , Adenoidectomia/métodos , Adolescente , Criança , Pré-Escolar , Medicina Baseada em Evidências , Feminino , Seguimentos , Humanos , Masculino , Medição de Risco , Apneia Obstrutiva do Sono/fisiopatologia , Tonsilectomia/métodos , Tonsilite/diagnóstico , Tonsilite/cirurgia , Resultado do Tratamento , Estados Unidos
6.
Otolaryngol Head Neck Surg ; 160(1_suppl): S1-S42, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30798778

RESUMO

OBJECTIVE: This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE: The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS: The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE: (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.


Assuntos
Doenças Faríngeas/cirurgia , Apneia Obstrutiva do Sono/cirurgia , Tonsilectomia , Criança , Humanos , Tonsilectomia/efeitos adversos , Tonsilectomia/métodos
7.
JAMA Otolaryngol Head Neck Surg ; 144(9): 776-780, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-30073253

RESUMO

Importance: Many treatments for clogged tympanostomy tubes (TTs) have been proposed, but none have met scientific rigor for safety and efficacy, including the popular empirical use of ototopical antibiotic drops. Dornase alfa, a recombinant molecule with the unique property of cleaving DNA, may be ideal in treating clogged TTs because both middle-ear effusion and the plug are abundant with DNA. Objective: To investigate the ototoxic effects of dornase alfa in a chinchilla model and its efficacy in a clinical trial in children with clogged TTs. Design, Setting, and Participants: The safety profiles of dornase alfa (full-strength and 1:10 strength) were evaluated in chinchilla middle ears using serial auditory brainstem response. The efficacy of ototopical dornase alfa (full-strength) was evaluated in children with clogged TTs in a prospective, single-blind randomized clinical trial. The animal study included 21 chinchillas and was conducted at Loma Linda University, Loma Linda, California, and the clinical trial was conducted at Children's Hospital Colorado, Aurora. A total of 40 children (50 ears with tubes) were enrolled. Interventions: In the animal study, chinchillas were assigned to 3 groups: controls (saline), full-strength dornase alfa, or 1:10 dornase alfa dilution. Children were randomly assigned to receive either topical dornase alfa or ofloxacin for clogged TT, 5 drops each ear twice a day for 7 days. Main Outcomes and Measures: Animal study: Auditory brainstem responses. Randomized trial of children participants: The primary outcome was patency of TT at day 14 assessed by otoscopy and tympanometry. Results: The chinchilla study showed similar auditory brainstem response degradation during a 6-hour period between the control (n = 5) and treatment groups (n = 21). In the clinical trial, a total of 40 clogged TTs (in 33 children, including 25 boys [76%]; mean age, 4.3 years; median [range] age, 3.4 [1.0-14.3] years) were analyzed. The number of unclogged TTs was higher in the dornase alfa group (13 [59%]) compared with the ofloxacin group (8 [44%]), with a difference of 15% (odds ratio, 1.8; 95% CI, 0.54-6.72). Conclusions and Relevance: The chinchilla model suggests that dornase alfa is likely nonototoxic. The pilot clinical trial failed to show efficacy of dornase alfa to unclog TTs. With the difference seen between the treatment groups, a sample size estimate could be calculated for a future large-scale trial. Trial Registration: ClinicalTrials.gov identifier: NCT00419380.


Assuntos
Desoxirribonuclease I/uso terapêutico , Falha de Equipamento , Potenciais Evocados Auditivos do Tronco Encefálico/efeitos dos fármacos , Ventilação da Orelha Média/instrumentação , Complicações Pós-Operatórias/tratamento farmacológico , Administração Tópica , Adolescente , Animais , Criança , Pré-Escolar , Chinchila , Desoxirribonuclease I/toxicidade , Feminino , Seguimentos , Humanos , Lactente , Masculino , Estudos Prospectivos , Proteínas Recombinantes/uso terapêutico , Proteínas Recombinantes/toxicidade , Método Simples-Cego , Resultado do Tratamento
8.
Int J Pediatr Otorhinolaryngol ; 105: 52-55, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29447819

RESUMO

OBJECTIVE: Evaluate peri-operative course and morbidity in children with Down syndrome (DS) who underwent a lingual tonsillectomy (LT) for residual obstructive sleep apnea (rOSA). METHODS: Retrospective case series for children with DS who underwent LT for rOSA from April 2011 to July 2016. Our primary outcomes were length of stay, readmission and complications. Surgical effectiveness was evaluated by change in the obstructive apnea-hypopnea-index(OAHI) and oxygen saturation nadir. RESULTS: Thirty-nine patients underwent LT. The mean length of stay was 1.3 days with n = 21(72%) staying one night. One subject (2.6%) had a post-operative bleed that did not require operative intervention. No other major complications occurred. In terms of effectiveness of surgery, twenty-nine children had sufficient data for inclusion. Median OAHI did not appreciably change (p = 0.07) from before surgery. Five subjects (17%) were cured of OSA (OAHI < 2/hour) and a mix of improvement and worsening was identified. The lowest oxygen saturation improved from 78% (SD = 7) before surgery to 82% (SD = 6) after surgery (p = 0.003). CONCLUSION: LT has a favorable post-operative course but its effectiveness at curing rOSA in the DS population has not been established/proven. Further research is indicated to determine optimal surgical management for DS children with LTH. LEVEL OF EVIDENCE: 4.


Assuntos
Síndrome de Down/cirurgia , Apneia Obstrutiva do Sono/cirurgia , Tonsilectomia/efeitos adversos , Adolescente , Criança , Pré-Escolar , Síndrome de Down/complicações , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Polissonografia , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório , Estudos Retrospectivos , Apneia Obstrutiva do Sono/complicações , Tonsilectomia/métodos , Resultado do Tratamento
9.
Otolaryngol Head Neck Surg ; 158(2): 364-367, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28871845

RESUMO

Objective In 2011, the American Academy of Pediatrics published a guideline for children with Down syndrome (DS), recommending a polysomnogram (PSG) by age 4 years regardless of symptoms. Their rationale was based on 2 publications with small cohorts, where at least 50% of the children had no obstructive sleep apnea (OSA) symptoms but their PSG results were abnormal. The American Academy of Otolaryngology-Head and Neck Surgery Foundation published a clinical practice guideline recommending PSG prior to adenotonsillectomy for these children. This study aimed to assess parents' accuracy of their children's breathing patterns as compared with PSGs in a larger cohort of children with DS. Study Design Case series with chart review. Setting Tertiary care academic pediatric hospital. Subjects and Methods Sleep intake forms assessing frequency of parent-observed apnea, snoring, and restless sleep were analyzed. None of the children had a previous tonsillectomy. Two groups were analyzed according to symptoms: infrequent (<3 nights per week on all questions answered) and frequent (≥6 nights per week on at least 1 question). OSA severity was categorized as follows: normal, <2 events per hour; mild, 2 to 4.9; moderate, 5 to 9.9; and severe, ≥10. Results A total of 113 children met inclusion criteria: 34% (n = 38) had infrequent symptoms, and 66% (n = 75) had frequent symptoms. Parents were unable to predict the presence or absence of OSA by nighttime symptoms ( P = .60). The risk of OSA for children with frequent symptoms versus those with infrequent symptoms was 1.04 (95% CI, 0.89-1.3). Conclusion Parents of DS children are unable to predict the presence or absence of OSA by nighttime symptoms, nor are they able to determine its severity.


Assuntos
Síndrome de Down/fisiopatologia , Pais/psicologia , Apneia Obstrutiva do Sono/fisiopatologia , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Polissonografia , Guias de Prática Clínica como Assunto , Índice de Gravidade de Doença
10.
J Clin Sleep Med ; 13(8): 975-980, 2017 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-28728615

RESUMO

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is common in children with Down syndrome (DS) and associated with significant morbidity. In the current study we examined polysomnographic outcomes of children with DS who underwent tonsillectomy. METHODS: A retrospective chart review of children with DS who underwent a tonsillectomy between 2009-2015 was performed. All children had either a concurrent adenoidectomy or had previously underwent an adenoidectomy. Children with preoperative and postoperative polysomnograms within 6 months of surgery were included in the analysis. Preoperative OSA severity was categorized by obstructive apnea-hypopnea index (OAHI) as follows: mild = 1.5-4.9 events/h; moderate = 5-9.9 events/h; severe ≥ 10 events/h. RESULTS: Seventy-five children with DS met inclusion criteria. The cohort included 41 males and 34 females with mean age of 5.1 years (± 3.6 years), range of 0.51-16.60 years. Preoperative OSA severity was as follows, mild = 8/75; moderate = 16/75; severe = 51/75. Cure rates varied depending on definition: 12% for OAHI < 1 event/h and 21% for OAHI < 2 events/h. 48% had residual OAHI < 5 events/h. On postoperative PSG 16/75 saw resolution (OAHI < 2) in OSA; mild = 21/75; moderate = 20/75; severe = 18/75. 48% moderate/severe patients saw conversion to mild or cure. Overall, tonsillectomy resulted in significant improvements in multiple respiratory parameters, including OAHI (OAHI; 21.3 ± 19.7 to 8.0 ± 8.1, P < .001), percent sleep time with oxygen saturations < 90% (19.0 ± 25.0 to 6.1 ± 10.1, P < .001), and percent sleep time with end-tidal carbon dioxide above 50 mmHg (7.7 ± 18.0 to 1.8 ± 6.6, P = .001). Average asleep oxygen saturation was associated with postoperative OSA severity. CONCLUSIONS: Children with DS and OSA who undergo tonsillectomy experience improvements in both respiratory event frequency and gas exchange but approximately half still have moderate to severe residual OSA.


Assuntos
Síndrome de Down/complicações , Apneia Obstrutiva do Sono/cirurgia , Tonsilectomia , Adenoidectomia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Polissonografia , Estudos Retrospectivos , Apneia Obstrutiva do Sono/complicações
11.
Laryngoscope ; 127(1): 266-272, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27311407

RESUMO

OBJECTIVES/HYPOTHESIS: The purpose of this investigation was to assess current drug-induced sleep endoscopy (DISE) practice patterns at centers that have published on the technique, to identify areas of agreement, and to identify areas of disagreement that may represent opportunities for improvement and standardization. STUDY DESIGN: Multi-institutional survey. METHODS: A survey was designed in two phases to evaluate preoperative assessment, intraoperative performance, and postoperative management of patients undergoing DISE. The survey was constructed iteratively in consultation with the all of the coauthors, each selected as an expert owing to their previous publication of one or more articles pertaining to pediatric DISE. In the first phase of survey creation, each expert was asked to provide narrative answers to questions pertaining to DISE. These responses served as the basis for a second survey. This second survey was then administered to all pediatric otolaryngologists at each respective institution. RESULTS: Overall, there was a low rate of agreement (33%) among the respondents; however, there was substantial agreement within institution, particularly for the use of anesthetic medications, the use of cine magnetic resonance imaging, and performance of bronchoscopy along with DISE. There was strong agreement among all respondents for performing DISE in a child with severe obstructive sleep apnea following adenotonsillectomy, regardless of comorbidities. CONCLUSION: This multi-institutional survey demonstrated a lack of consensus between experts and multiple opportunities for improvement. In general, there was agreement regarding the workup prior to DISE performance and the endoscopic protocol but disagreement regarding anesthetic protocol and management decisions. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:266-272, 2017.


Assuntos
Anestesia/métodos , Endoscopia/métodos , Pediatria/métodos , Padrões de Prática Médica/estatística & dados numéricos , Apneia Obstrutiva do Sono/cirurgia , Sono/efeitos dos fármacos , Feminino , Humanos , Masculino , Seleção de Pacientes , Inquéritos e Questionários
12.
J Clin Sleep Med ; 12(6): 879-84, 2016 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-27092702

RESUMO

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a common pediatric condition characterized by recurrent partial or complete cessation of airflow during sleep, typically due to inadequate upper airway patency. Continuous positive airway pressure (CPAP) is a therapeutic option that reduces morbidity. Despite efforts to promote use, CPAP adherence is poor in both pediatric and adult populations. We sought to determine whether demographics, insurance status, OSA severity, therapeutic pressure, or comorbid conditions were associated with pediatric CPAP adherence. METHODS: A retrospective review of adherence download data was performed on all pediatric patients with initiation or adjustment of CPAP treatment over a one-year period with documented in-laboratory CPAP titration. Patients were grouped as CPAP adherent or non-adherent, where adherence was defined as > 70% nightly use and average usage ≥ 4 hours per night. Differences between the groups were analyzed by χ(2) test. RESULTS: Overall, nearly half of participants were CPAP adherent (49%, 69/140). Of the demographic data collected (age, ethnicity, sex, insurance status), only female sex was associated with better adherence (60.9% vs 39.5% of males adherent; odds ratio [OR] = 2.41, 95%CI = 1.20-4.85; p = 0.01). Severity of OSA (diagnostic apnea-hypopnea index [AHI] and degree of hypoxemia), therapeutic pressure, and residual AHI did not impact CPAP adherence (p > 0.05). Patients with developmental delay (DD) were more likely to be adherent with CPAP than those without a DD diagnosis (OR = 2.55, 95%CI = 1.27-5.13; p = 0.007). Female patients with trisomy 21 tended to be more adherent, but this did not reach significance or account for the overall increased adherence associated with female sex. CONCLUSIONS: Our study demonstrates that adherence to CPAP therapy is poor but suggests that female sex and developmental delay are associated with better adherence. These findings support efforts to understand the pathophysiology of and to develop adherence-promoting and alternative interventions for pediatric OSA.


Assuntos
Pressão Positiva Contínua nas Vias Aéreas/métodos , Cooperação do Paciente/estatística & dados numéricos , Apneia Obstrutiva do Sono/terapia , Criança , Feminino , Humanos , Masculino , Polissonografia , Estudos Retrospectivos
13.
JAMA Otolaryngol Head Neck Surg ; 142(5): 452-6, 2016 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-27010313

RESUMO

IMPORTANCE: Pediatric adenotonsillectomy is a frequently performed procedure. Few studies have examined perioperative practice patterns for children undergoing adenotonsillectomy. OBJECTIVE: To assess current group practice patterns associated with the perioperative care of children undergoing adenotonsillectomy for sleep-disordered breathing at tertiary care children's hospitals following the release of the 2011 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) clinical practice guidelines. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey was distributed to the chiefs of 72 pediatric otolaryngology divisions at tertiary care children's hospitals in the United States and Canada from March 25 to April 16, 2014. MAIN OUTCOMES AND MEASURES: Internet-based survey responses from the chiefs of pediatric otolaryngology at tertiary care children's hospitals in the United States and Canada, who responded regarding group, rather than individual, practices. RESULTS: Of the 72 surveys sent, 48 responses (67%) were received. Twenty-one respondents (44%) reported that their group has no official admission policy for children with sleep-disordered breathing. Seventy-three percent (29 of 40) reported using some measure of obesity as a criterion for postoperative admission. The AAO-HNS polysomnography criteria for severe obstructive sleep apnea were used by 40% of respondents (16 of 40) as admission criteria, whereas 15% (6 of 40) used the American Academy of Pediatrics criteria for severe obstructive sleep apnea. Seventy-three percent (29 of 40) reported requiring a child to be asleep while breathing room air without oxygen desaturation before discharge to home. An established minimum time for observation was reported by 43 of the respondents (90%). Institution size or volume of adenotonsillectomies performed did not affect the results. CONCLUSIONS AND RELEVANCE: Many tertiary care children's hospitals in the United States do not have an official admission policy to guide adenotonsillectomy care. Even for institutions that do have an official admission policy, the policies are not universally aligned with the AAO-HNS clinical practice guidelines. These survey results demonstrate an opportunity to improve quality and safety regarding admission policy practice patterns after pediatric adenotonsillectomy.


Assuntos
Adenoidectomia , Política Organizacional , Admissão do Paciente , Padrões de Prática Médica/estatística & dados numéricos , Tonsilectomia , Índice de Massa Corporal , Canadá , Estudos Transversais , Fidelidade a Diretrizes , Hospitais Pediátricos , Humanos , Obesidade Pediátrica , Assistência Perioperatória , Guias de Prática Clínica como Assunto , Apneia Obstrutiva do Sono/diagnóstico , Centros de Atenção Terciária , Estados Unidos
14.
Otolaryngol Head Neck Surg ; 154(1): 171-4, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26307581

RESUMO

Lingual tonsil hypertrophy (LTH) is a common finding for children with residual obstructive sleep apnea (OSA) following an adenotonsillectomy. Secondary to the significant morbidity associated with OSA, identification and treatment of residual OSA are paramount. A dedicated LTH grading scale for children does not exist. The current adult LTH scale is impractical for children. Imaging is not routine for children, since it frequently requires sedation. We present a pediatric LTH grading scale with substantial interrater reliability to facilitate standardization of endoscopy findings and promote outcomes-based research for OSA surgery in children.


Assuntos
Tonsila Palatina/patologia , Criança , Humanos , Hipertrofia/patologia , Índice de Gravidade de Doença , Apneia Obstrutiva do Sono/etiologia , Língua
15.
JAMA Pediatr ; 169(12): 1155-61, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26436644

RESUMO

Adenotonsillectomy is one of the most common surgical procedures performed in children, with more than half a million procedures performed annually. We provide a review of the procedure, including indications, contraindications, perioperative issues, and current controversies. A more in-depth discussion of indications for sleep-disordered breathing and recurrent throat infections is performed. We provide a reasonable approach to these conditions for the general pediatrician. Finally, we discuss selected areas of current controversies: the role of preoperative polysomnogram, postoperative weight gain, and effects on immune function.


Assuntos
Adenoidectomia/métodos , Síndromes da Apneia do Sono/cirurgia , Tonsilectomia/métodos , Adenoidectomia/efeitos adversos , Criança , Humanos , Polissonografia , Tonsilectomia/efeitos adversos
16.
Int J Pediatr Otorhinolaryngol ; 79(6): 903-8, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25912628

RESUMO

INTRODUCTION: To study characteristics of children less than 2 years who underwent a tonsillectomy for sleep disordered breathing (SDB) or obstructive sleep apnea (OSA) to assess for factors associated with requesting a preoperative polysomnogram (PSG) and to identify predictors of upper airway obstruction in this group. MATERIALS AND METHODS: A retrospective chart review of children under 2 years who underwent a tonsillectomy over a 7-year period at a tertiary care pediatric hospital was undertaken. Patient demographics, characteristics and polysomnography results, when applicable, were collected. In order to determine if the gathered demographics of our cohort differed from the non-surgical population, we compared our data with available Colorado data for each variable. Children were stratified by OSA severity using their obstructive apnea-hypopnea index (OAHI). RESULTS: 197 (2.2%) of 9038 patients who underwent tonsillectomy for SDB or OSA were ≤ 24 months. The proportions of male, African-American, Hispanic, obese, underweight, premature, syndromic and daycare patients in our cohort were significantly different than in the general population. In a multivariate model, the odds of African-Americans having severe OSA were 12.5 times greater than the odds of Caucasians. The odds of patients with syndromes or craniofacial anomalies were 11 times greater (p < 0.0001), and the odds of patients in daycare were 2.2 times lower (p = 0.04) of undergoing a PSG before tonsillectomy. Weight did not influence polysomnogram requests. CONCLUSIONS: In children under 2 years, ethnicity seems to be a predictor of OSA severity. African-American, prematurity, daycare and Down syndrome patients were significantly more represented in our study population. PSG is more likely to be requested for syndromic children.


Assuntos
Obstrução das Vias Respiratórias/cirurgia , Anormalidades Craniofaciais/epidemiologia , Apneia Obstrutiva do Sono/cirurgia , Tonsilectomia , Adenoidectomia , Afro-Americanos/estatística & dados numéricos , Colorado/epidemiologia , Comorbidade , Síndrome de Down/epidemiologia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Obesidade/epidemiologia , Polissonografia , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/etnologia , Magreza/epidemiologia
17.
Int J Pediatr Otorhinolaryngol ; 79(5): 666-70, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25736546

RESUMO

PURPOSE: Friedman tongue position (FTP) may play an important role in the evaluation of children with sleep-related breathing disorders (SRBD), but there are no previous data on FTP distribution by age. The objective of the current study was to determine the distribution of FTP by age and examine the relationship between FTP and snoring in children. METHODS: Prospective cross-sectional study of 199 children (mean age, 6.8 years; 59% male) had tongue position assessed by FTP as part of their clinical examination of the oral cavity during routine ENT visits at a tertiary care children's hospital. The FTP and snoring frequency of participants was examined across the entire age range as well as by comparing those older (middle childhood and above) and younger than 5 years of age. RESULTS: Tongue position did not correlate with age or snoring frequency. The proportion of children with FTP III/IV was not significantly different in children younger than five years of age compared to older than five. Habitual snoring was not associated with having a higher FTP. Among children who snored <3 times per week, those who had previously undergone tonsillectomy did have higher FTP compared to those who had not (p=0.007). BMI-%-for-age was significantly correlated with FTP (p=0.003). The percent of children having FTP class III/IV differed significantly between ethnicities (22% of whites, 26% of others, 45% of hispanics, 53% of African-Americans; p=0.011). Inter-rater reliability among pediatric otolaryngologist was excellent (kappa=0.93, p<0.001). CONCLUSIONS: There does not appear to be an association between FTP with age or snoring frequency in children. The excellent inter-rater reliability for FTP among pediatric ENT providers suggests the null findings are not due to rater bias. These findings may serve as an important reference for those studying the role of tongue position in pediatric SRBD and complement previous studies examining FTP among children with known OSA or snoring.


Assuntos
Síndromes da Apneia do Sono/diagnóstico , Língua/anatomia & histologia , Adolescente , Distribuição por Idade , Índice de Massa Corporal , Criança , Pré-Escolar , Grupos de Populações Continentais , Estudos Transversais , Feminino , Humanos , Masculino , Estudos Prospectivos , Reprodutibilidade dos Testes , Ronco/etiologia
18.
JAMA Otolaryngol Head Neck Surg ; 141(3): 236-44, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25555106

RESUMO

IMPORTANCE: Children undergoing urgent adenotonsillectomy have been poorly described in literature. OBJECTIVE: To characterize the clinical course and outcomes of patients who underwent urgent adenotonsillectomy. DESIGN, SETTING, AND PARTICIPANTS: A 7-year retrospective medical record review of patients undergoing urgent adenotonsillectomy (study group) at a tertiary care pediatric hospital was undertaken. Comparisons were made between the study group and the control group consisting of children undergoing adenotonsillectomy following diagnostic polysomnography. INTERVENTIONS: Retrospective medical record review with no study interventions. MAIN OUTCOMES AND MEASURES: Demographics, hospital course, and clinical outcomes. RESULTS: A total of 35 patients (21 boys [60%] and 14 girls [40%]; mean age, 3.8 years) were identified as having undergone urgent adenotonsillectomy defined as severe obstructive sleep apnea with associated hypoxemia unresponsive to oxygen. The control group included 301 patients who received a diagnostic polysomnogram prior to nonurgent adenotonsillectomy. Patients undergoing urgent adenotonsillectomy patients were more likely to be younger than 3 years (54%) than nonurgent patients (P < .001) and were characterized by elevated obstructive apnea-hypopnea indices (average, 39.4 events per hour). Persistent desaturation below 80% despite at least 0.5 L of supplemental oxygen was the most common admission indication (83%). Obesity was the most frequent comorbidity (9 patients [31%]). Two patients (6%) experienced a major postoperative complication requiring intervention. Fifteen patients (43%) were discharged with supplemental oxygen. Two patients (6%) were admitted to the hospital more than 72 hours after surgery. CONCLUSIONS AND RELEVANCE: Patients requiring urgent adenotonsillectomy are marked by younger age, elevated obstructive apnea-hypopnea indices, and persistent desaturations below 80% unresponsive to supplemental oxygen. Following surgery, some children have a dramatic improvement in gas exchange and will no longer require supplemental oxygen.


Assuntos
Adenoidectomia , Emergências , Hipóxia/cirurgia , Avaliação de Resultados da Assistência ao Paciente , Apneia Obstrutiva do Sono/cirurgia , Tonsilectomia , Estudos de Casos e Controles , Criança , Pré-Escolar , Feminino , Humanos , Hipóxia/etiologia , Lactente , Masculino , Obesidade/complicações , Oxigênio/sangue , Oxigenoterapia/estatística & dados numéricos , Readmissão do Paciente , Complicações Pós-Operatórias , Estudos Retrospectivos , Índice de Gravidade de Doença , Apneia Obstrutiva do Sono/complicações
19.
Curr Opin Otolaryngol Head Neck Surg ; 21(6): 557-66, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24240132

RESUMO

PURPOSE OF REVIEW: With the increased awareness of the morbidity associated with snoring, polysomnography (PSG) is becoming more prevalent. Many national organizations have recently published clinical guidelines to facilitate decision-making for children with disrupted breathing patterns. This review will discuss these clinical guidelines and describe the rationale behind them. It will also touch on the limitations of PSG. RECENT FINDINGS: The common theme for the clinical guidelines is that PSG is being underutilized. Not only is obstructive sleep apnea (OSA) associated with behavioral, cognitive, and cardiovascular morbidity, but primary snoring is also not always benign. The interpretation of the PSG is influenced by multiple variables: filter settings, sensors utilized, and how the respiratory events are tabulated. SUMMARY: To diagnose OSA, one requires overnight PSG. Multiple guidelines have been published to facilitate decision-making. Many questions remain unanswered and future research as well as PSG standardization will further clarify the role of PSG in the evaluation and treatment of disrupted breathing patterns in children.


Assuntos
Polissonografia , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/etiologia , Ronco/etiologia , Fatores Etários , Criança , Pré-Escolar , Humanos , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Apneia Obstrutiva do Sono/fisiopatologia , Ronco/diagnóstico , Ronco/fisiopatologia
20.
Laryngoscope ; 123(4): 1055-8, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23382017

RESUMO

OBJECTIVES/HYPOTHESIS: Since the primary therapy for children with sleep-disordered breathing(SDB) is adenotonsillectomy, a survey was developed to determine the current practice patterns for children with SDB by pediatric otolaryngologists. STUDY DESIGN: Cross-sectional survey METHODS: An Internet-based survey was sent to all American Society of Pediatric Otolaryngology members. In addition to descriptive statistics, a logistic regression was performed to assess if years in practice, polysomnogram (PSG) wait time, or frequency of evaluating snoring children changes management. RESULTS: The response rate was 39% (135/345). Children with SDB were "most of the time" referred for PSGs by 4% of respondents. Sixty-five percent referred for PSG "sometimes," and 31% referred "rarely" or "never." An increased wait time was a significant predictor of PSG frequency (OR = 1.10, 95% CI: 0.92-1.0, P = 0.039). Children with Down syndrome or obesity had preoperative PSG requested "always" 20% and 8% of the time. The primary reason for requesting a PSG in a normal child was inconsistent clinical evaluation (58%). To diagnose obesity, most (72%) record height and weight, but only 34% record BMI% for age. Overnight observation was performed "most of the time" for the following groups: Obese (70%), Down syndrome (83%), and <3 years (83%). CONCLUSIONS: Pediatric otolaryngologists are noncompliant with the 2002 American Academy of Pediatrics and the 2011 American Academy of Otolaryngology-Head and Neck Surgery guidelines. Despite noncompliance, they fortunately have a lower threshold to monitor high-risk children overnight following surgery. The recommended Center for Disease Control measures to diagnose childhood obesity occasionally are being utilized. An educational campaign is necessary to update clinicians who take care of children on the new evidence-based guidelines.


Assuntos
Prática Profissional , Síndromes da Apneia do Sono/diagnóstico , Síndromes da Apneia do Sono/terapia , Adenoidectomia , Criança , Estudos Transversais , Pesquisas sobre Serviços de Saúde , Humanos , Internet , Polissonografia , Padrões de Prática Médica , Ronco/diagnóstico , Ronco/terapia , Tonsilectomia
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