Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline.

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

The effect of time until surgical intervention on survival in dogs with secondary septic peritonitis.

This retrospective study examined the effect of time to intervention on outcome in cases of dogs with secondary septic peritonitis, and also searched for other potential prognostic factors. The medical records of 55 dogs were reviewed. No association was found between outcome and the time from hospital admission to surgical source control. However, several other factors were found to influence survival, including: age, needing vasopressors, lactate, pre-operative packed cell volume, serum alkaline phosphatase, serum total bilirubin, and post-operative serum albumin. These values were then used to create accurate pre- and post-operative survival prediction models.

Effet du délai jusqu'à l'intervention chirurgicale sur la survie des chiens atteints de péritonite septique secondaire. Cette étude rétrospective a examiné l'effet du délai jusqu'à l'intervention sur le résultat dans les cas de chiens atteints de péritonite septique secondaire et a aussi cherché d'autres facteurs de pronostic potentiel. Les dossiers médicaux de 55 chiens ont été examinés. Aucune association n'a été trouvée entre le résultat et le délai entre l'admission à l'hôpital et le contrôle chirurgical de la source. Cependant, on a constaté que plusieurs autres facteurs influençaient la survie : l'âge, le besoin de vasopresseurs, le lactate, la valeur d'hématocrite avant l'opération, la phosphatase alcaline sérique, la bilirubine totale sérique et l'albumine sérique post-opératoire. Ces valeurs ont ensuite été utilisées pour créer des modèles de prédiction de la survie exacts avant et après l'opération.(Traduit par Isabelle Vallières).

Strategies to Assess the Effect of Continuous Positive Airway Pressure on Long-Term Clinically Important Outcomes among Patients with Symptomatic Obstructive Sleep Apnea: An Official American Thoracic Society Workshop Report.

Continuous positive airway pressure (CPAP) is the first-line treatment for obstructive sleep apnea (OSA). Although CPAP improves symptoms (e.g., daytime sleepiness), there is a lack of high-quality evidence that CPAP prevents many long-term outcomes, including cognitive impairment, myocardial infarction, and stroke. Observational studies suggest that patients with symptoms may be particularly likely to experience these preventive benefits with CPAP, but ethical and practical concerns limited the participation of such patients in prior long-term randomized trials. As a result, there is uncertainty about the full benefits of CPAP, and resolving this uncertainty is a key priority for the field. This workshop assembled clinicians, researchers, ethicists, and patients to identify strategies to understand the causal effects of CPAP on long-term clinically important outcomes among patients with symptomatic OSA. Quasi-experimental designs can provide valuable information and are less time and resource intensive than trials. Under specific conditions and assumptions, quasi-experimental studies may be able to provide causal estimates of CPAP's effectiveness from generalizable observational cohorts. However, randomized trials represent the most reliable approach to understanding the causal effects of CPAP among patients with symptoms. Randomized trials of CPAP can ethically include patients with symptomatic OSA, as long as there is outcome-specific equipoise, adequate informed consent, and a plan to maximize safety while minimizing harm (e.g., monitoring for pathologic sleepiness). Furthermore, multiple strategies exist to ensure the generalizability and practicality of future randomized trials of CPAP. These strategies include reducing the burden of trial procedures, improving patient-centeredness, and engaging historically excluded and underserved populations.

Comparison of Outcome and Complications in Dogs Weighing Less Than 12 kg Undergoing Miniature Tibial Tuberosity Transposition and Advancement versus Extracapsular Stabilization with Tibial Tuberosity Transposition for Cranial Cruciate Ligament Disease with Concomitant Medial Patellar Luxation.

OBJECTIVE: The aim of this study was to describe a technique for performing miniature tibial tuberosity transposition and advancement (mTTTA). The secondary objective of this study was to compare the short-term outcome and complications in small breed dogs weighing less than 12 kg undergoing surgical correction of cranial cruciate ligament disease with concurrent medial patellar luxation via either extracapsular stabilization with tibial tuberosity transposition (ECS + TTT) or mTTTA. STUDY DESIGN: This is a retrospective case comparison study. RESULTS: There was no significant difference in overall outcome between the ECS + TTT group and the mTTTA group when comparing 8-week postoperative radiographic healing scores as well as 2- and 8-week postoperative lameness scores. CONCLUSION: This study concluded that the mTTTA procedure was feasible and the overall outcome and complications for the dogs that underwent ECS + TTT and those that underwent mTTTA were comparable.

Sleep Difficulties and Medications in Children With Autism Spectrum Disorders: A Registry Study.

OBJECTIVES: Sleep difficulties are common in children with autism spectrum disorders, with wide-ranging effects on the child's daytime behavior. We reviewed data within our Autism Speaks Autism Treatment Network Registry to determine the prevalence of sleep difficulties and patterns of medication use. METHODS: Data from 1518 children ages 4 to 10 years were analyzed to determine the number of children documented to have sleep difficulties by parent-completed questionnaires and clinician-completed forms and how these findings related to the use of sleep medications. RESULTS: The Children's Sleep Habits Questionnaire total score was ≥41 (associated with clinically significant sleep problems in past research) in 71% of children. The prevalence of sleep diagnoses was less frequent (30% of children aged 4-10 years; P < .0001). Medications for sleep were prescribed in 46% of 4- to 10-year-olds given a sleep diagnosis. The most common medication used for sleep was melatonin followed by α-agonists, with a variety of other medications taken for sleep (anticonvulsants, antidepressants, atypical antipsychotics, and benzodiazepines). Children taking medications for sleep had worse daytime behavior and pediatric quality of life than children not taking sleep medications. CONCLUSIONS: Parent concerns about sleep may not be reflected in the information gathered during a clinic visit, supporting the need to develop screening practice pathways for sleep in autism spectrum disorders. Furthermore, many medications taken for sleep have adverse effects, supporting the need for evidence-based interventions in this population.

Sleep and sedation in the pediatric intensive care unit.

Sleep is an important and necessary function of the human body. Somatic growth and cellular repair occur during sleep. Critically ill children have disturbed sleep while in the pediatric intensive care unit related both to the illness itself and to light, noise, and caregiver activities disrupting an environment conducive to sleep. Medications administered in the pediatric intensive care unit can also disrupt sleep. This article reviews what is known about sleep in the pediatric intensive care unit and the effects of common sedation medications on sleep.

Sleep monitoring in children during neuromuscular blockade in the pediatric intensive care unit: a pilot study.

BACKGROUND: Sleep is an important physiologic process that is known to be disrupted in the intensive care unit. Nevertheless, there is little information on how intensive care unit admission affects sleep in children. Because laryngotracheoplasty is elective but entails 5-7 days of neuromuscular blockade following surgery, children undergoing this procedure present a unique opportunity to analyze sleep during neuromuscular blockade apart from confounding variables resulting from critical illness. OBJECTIVE: To determine the feasibility of using polysomnography to assess sleep patterns in children during neuromuscular blockade. METHODS: Polysomnography recordings were obtained continuously for 4 days (96 hrs) in two children following laryngotracheoplasty. Medication administration (neuromuscular blockades, sedatives) and time of suctioning were also recorded. RESULTS: Both subjects had documented sleep. However, the proportion of time in each stage was markedly different from developmental norms, and a greater proportion of sleep occurred during the day. Furthermore, there was substantial day-night and day-to-day variability. Some rebound of consolidated sleep appeared by day 4. Sedative use varied considerably. However, neither bolus sedation administration nor endotracheal suctioning appeared to affect sleep. Few monitoring difficulties were encountered. CONCLUSIONS: Sleep can be monitored with minimal difficulty in children undergoing neuromuscular blockade in the pediatric intensive care unit. Sleep occurred throughout the day, and there was considerable fragmentation. To fully assess sleep in the intensive care unit, monitoring needs to be continuous over several days, rather than only at night or for < or =24 hrs. Further research is needed in the area to determine typical sleep patterns in children undergoing neuromuscular blockade.

The longitudinal association of young children's everyday routines to sleep duration.

INTRODUCTION: Everyday routines promote children's health. In the present study, we examined whether children's participation in everyday routines at ages 4 and 6 years predicted their sleep duration at age 6 years. METHOD: A secondary analysis of data was performed for 177 families who participated in the Rochester Preschool Children Injuries Study. Mothers were interviewed when their children were ages 4 and 6 years and reported on their children's everyday routines and perceived sleep duration. Relationships were examined by multiple hierarchical regression analysis. RESULTS: It was found that children who participated in more frequent routines at age 4 years were more likely to do so at age 6 years. Children's inadequate sleep duration at age 6 years was predicted by less frequent routines at age 6 years and by inadequate sleep duration at age 4 years after controlling for mothers' ethnicity, mothers' education, and family structure. An indirect relationship of routines at age 4 years to sleep at age 6 years through routines at age 6 years was found. DISCUSSION: Continuous engagement in everyday routines seems to play an important role in children's sleep acquisition.

Sleep associated gas exchange abnormalities in children and adolescents with habitual snoring.

STUDY OBJECTIVES: The purpose of this study was to describe the prevalence of polysomnographically diagnosed OSAS and to describe the severity of sleep associated gas exchange abnormalities (SAGEA) in habitually snoring children. We hypothesized that there would be a high prevalence of OSAS in obese children with habitual snoring and that the most overweight children would have the most significant SAGEA. DESIGN: Retrospective chart review. MEASUREMENTS AND RESULTS: Nocturnal polysomnography (NPSG) data from 114 children and adolescents referred for habitual snoring were examined. 74 of the subjects were male (65%), average age of 9.78 +/- 4.19 years, average AHI 13.51 +/- 20.25, mean BMI z-score 1.79 +/- 1.18. BMI z-scores correlated positively with severity of OSAS (P < 0.05) such that children with progressive degrees of obesity had more frequent respiratory events during sleep. Additionally, severity of sleeping hypercapnea as measured by percent of total sleep time with EtCO(2) values above 50 mm Hg was more severe with progressive degrees of obesity. Likewise, all measures of oxyhemoglobin desaturation were more severe with progressive degrees of obesity. Positive correlations between the severity of SAGEA and degree of obesity remained even after controlling for the severity of OSAS. CONCLUSIONS: OSAS is highly prevalent in children referred to a pediatric sleep center with complaints of habitual snoring across a wide spectrum of weight categories. SAGEA increases with progressive obesity even when controlling for the severity of OSAS suggesting that obesity is an independent risk factor for SAGEA. Furthermore, because obese children frequently have SAGEA, capnography should be obtained during NPSG when possible.

Sleep-disordered breathing and behaviors of inner-city children with asthma.

OBJECTIVE: To explore the relationship between sleep-disordered breathing (SDB) and behavioral problems among inner-city children with asthma. METHODS: We examined data for 194 children (aged 4-10 years) who were enrolled in a school-based asthma intervention program (response rate: 72%). SDB was assessed by using the Sleep-Related Breathing Disorder Questionnaire that contains 3 subscales: snoring, sleepiness, and attention/hyperactivity. For the current study, we modified the Sleep-Related Breathing Disorder Questionnaire by removing the 6 attention/hyperactivity items. A sleep score of >0.33 was considered indicative of SDB. To assess behavior, caregivers completed the Behavior Problem Index (BPI), which includes 8 behavioral subdomains. We conducted bivariate analyses and multiple linear regression to determine the association of SDB with BPI scores. RESULTS: The majority of children (mean age: 8.2 years) were male (56%), black (66%), and insured by Medicaid (73%). Overall, 33% of the children experienced SDB. In bivariate analyses, children with SDB had significantly higher (worse) behavior scores compared with children without SDB on total BPI (13.7 vs 8.8) and the subdomains externalizing (9.4 vs 6.3), internalizing (4.4 vs 2.5), anxious/depressed (2.4 vs 1.3), headstrong (3.2 vs 2.1), antisocial (2.3 vs 1.7), hyperactive (3.0 vs 1.8), peer conflict (0.74 vs 0.43), and immature (2.0 vs 1.5). In multiple regression models adjusting for several important covariates, SDB remained significantly associated with total BPI scores and externalizing, internalizing, anxious/depressed, headstrong, and hyperactive behaviors. Results were consistent across SDB subscales (snoring, sleepiness). CONCLUSIONS: We found that poor sleep was independently associated with behavior problems in a large proportion of urban children with asthma. Systematic screening for SDB in this high-risk population might help to identify children who would benefit from additional intervention.

Symptoms of sleep apnea and polysomnography as predictors of poor quality of life in overweight children and adolescents.

OBJECTIVE: The goal of this study was to examine the relationship between quality of life (QOL) and symptoms of obstructive sleep apnea (OSA) as well as objectively measured severity of OSA using polysomnography (PSG) in a cohort of overweight and at risk for overweight children and adolescents. METHODS: One hundred and fifty-one overweight subjects [90 males, average ages of 12.52, mean body mass index (BMI) Z-score of 2.27) and their parent/guardian completed surveys assessing QOL and symptoms of OSA syndrome. The subjects also underwent overnight PSG. RESULTS: Overweight patients reported poor QOL. Polysomnographic variables did not correlate with QOL. However, symptoms of OSA as reported on the Pediatric Sleep Questionnaire significantly correlated with QOL from both the parent and the subject. CONCLUSIONS: Overweight youth with symptoms of OSA have a lower QOL both by their report and parental report. Interestingly, objective measures of OSA did not correlate with QOL.

Developmental stages of sleep from birth to adolescence, common childhood sleep disorders: overview and nursing implications.

Sleep is an important physiological process with profound impact on the body. Sleep undergoes normal developmental changes and common sleep problems are seen in general pediatric practice. This article discusses normal developmental changes related to sleep, common sleep disorders experienced by children and how nurses can assist parents in coping with these changes and disorders.