Poor sleep quality and its associated neurocognitive function in children with obesity with or without obstructive sleep apnea.

OBJECTIVE: To evaluate the associations of OSA severity, snoring symptoms, subjective sleep quality, and daytime sleepiness with executive functioning and behaviors in children with obesity. METHODS: This was a cross-sectional study of children aged 8-18 years with obesity and symptoms suggestive of OSA. All participants underwent an overnight polysomnography and completed a set of questionnaires to assess their sleep-related breathing disordered (SRBD) symptoms [Pediatric Sleep Questionnaire (SRBD-PSQ)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], executive function [Behavior Rating Inventory of Executive Function (BRIEF)], and inattention and hyperactivity symptoms (Conners-3 Parent Short Form). RESULTS: A total of 85 children (62% male, mean age: 13.9 ± 3.0 years) were included in this analysis, of whom 36, 16, and 33 were categorized into the non-OSA (obstructive apnea hypopnea index, OAHI < 1.5/h), mild OSA (OAHI 1.5-5/h), and moderate-severe OSA (OAHI ≥ 5/h) groups, respectively. Of 85 participants, 27 (32%) were classified with poor sleep quality (PSQI composite score ≥ 8). From multiple linear regression analyses, poor sleep quality and sleepiness were both independently associated with higher BRIEF behavioral regulation T-score, metacognition T-score, and global executive composite T-score in the fully adjusted model. In addition, poor sleep quality was also independently associated with higher Conners-3 inattention and executive functioning T-scores, while greater sleepiness was also associated with a higher learning problem T-score. The presence of OSA and snoring were not associated with any cognitive outcomes. CONCLUSIONS: Subjective sleep quality and daytime sleepiness, but not OSA severity and snoring symptoms, were independently associated with executive functioning and behavioral problems in children with obesity.

The impact of the COVID-19 pandemic on positive airway pressure usage in children with sleep-disordered breathing.

PURPOSE: To evaluate the impact of the COVID-19 pandemic on non-invasive positive airway pressure (PAP) usage among children with sleep-disordered breathing (SDB). METHODS: PAP usage data in children with SDB aged 1 to 18 years old at The Hospital for Sick Children, Canada, were analyzed. The PAP usage data were recorded for 3 months prior to and 3 months following the COVID-19 lockdown in Ontario, Canada. The primary outcomes of interest were (i) percentage of days that PAP was used for ≥ 4 h and (ii) average daily usage of PAP based on days when PAP was used. RESULTS: A total of 151 children were included. The mean (± SD) age and BMI were 12.6 ± 4.1 years and 28.7 ± 12.4 kg/m2, respectively. The median (IQR) percentage of days of PAP usage for ≥ 4 h and average nightly PAP usage was significantly higher during compared with prior to the pandemic (76.7 [19.0-94.0] vs 62.0 [15.5-89.0]%, p = 0.02, and 406.0 [244.0-525.0] vs 367.0 [218.0-496.0] min, p = 0.006, respectively). Within this cohort, 95/151 (63%) children with SDB showed increased PAP usage and 56/151 (37%) either decreased the amount of time they used PAP or stopped PAP use altogether. CONCLUSIONS: COVID-19 pandemic has provided opportunities for increased PAP usage in a significant number of children with SDB. A subset of children with prior evidence for suboptimal PAP usage showed further decreases in PAP usage during the pandemic. This information is critical for clinicians to provide anticipatory guidance to encourage PAP usage both during the pandemic and beyond.

Obstructive sleep apnea in children aged 3 years and younger: Rate and risk factors.

OBJECTIVE: Undiagnosed and untreated obstructive sleep apnea (OSA) can predispose children to neurobehavioural consequences. However, there is a lack of data identifying rate of, and risk factors for, OSA in very young healthy children. The objective of this study was to determine the rate of OSA and identify risk factors associated with the presence and severity of OSA in children aged 3 years and younger. METHODS: This was a retrospective chart review of healthy children between 1 and 3 years old who had a baseline polysomnogram (PSG) between January 2012 and June 2017. Patient demographics, referral history, and PSG data were recorded. RESULTS: One hundred and thirteen children were referred for a PSG, of which 66 (58%) were diagnosed with OSA and 47 (42%) did not have OSA. In the OSA group, 13 (20%) were mild and 53 (80%) were moderate-severe. Nasal congestion (P=0.001), adenoid hypertrophy (P=<0.001), and tonsillar hypertrophy (P=0.04) reported at the time of referral were more common in the OSA group compared to the no-OSA group. Binary logistic regression analysis showed that referral from an otolaryngologist (odds ratio=2.6, 95% confidence interval=1.1 to 6.0) were associated with moderate-severe OSA. CONCLUSION: A high rate of OSA was found among children aged 3 years and younger. Children referred by an otolaryngologist are more likely to be diagnosed with moderate-severe OSA. Children aged 3 years and younger with symptoms of OSA should be considered high-risk for OSA and be prioritized for early PSG and management.

Identification of obstructive sleep apnea in children with obesity: A cluster analysis approach.

BACKGROUND: Obstructive sleep apnea (OSA) is a heterogeneous disorder with a prevalence of 25%-60% in children with obesity. There is a lack of diagnostic tools to identify those at high risk for OSA. METHOD: Children with obesity, aged 8-19 years old, were enrolled into an ongoing multicenter, prospective cohort study related to OSA. We performed k-means cluster analysis to identify clinical variables which could help identify obesity related OSA. RESULTS: In this study, 118 participants were included in the analysis; 40.7% were diagnosed with OSA, 46.6% were female and the mean (SD) body mass index (BMI) and age were 39.7 (9.6) Kg/m², and 14.4 (2.6) years, respectively. The mean (SD) obstructive apnea-hypopnea index (OAHI) was 11.0 (21.1) events/h. We identified two distinct clusters based on three clustering variables (age, BMI z-score, and neck-height ratio [NHR]). The prevalence of OSA in clusters 1 and 2, were 22.4% and 58.3% (p = 0.001), respectively. Children in cluster 2, in comparison to cluster 1, had higher BMI z-score (4.7 (1.1) versus 3.2 (0.7), p < 0.001), higher NHR (0.3 (0.02) versus 0.2 (0.01), p < 0.001) and were older (15.0 (2.2) versus 13.7 (2.9) years, p = 0.09), respectively. However, there were no significant differences in sex and OSA symptoms between the clusters. The results from hierarchical clustering were similar to k-means analysis suggesting that the resulting OSA clusters were stable to different analysis approaches. INTERPRETATION: BMI, NHR, and age are easily obtained in a clinical setting and can be utilized to identify children at high risk for OSA.

The association between sleep quality and obstructive sleep apnea with health-related quality of life in children with obesity.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) and poor sleep quality are highly prevalent in children with obesity, but their individual associations with health-related quality of life (HRQOL) are unknown in this population. The primary objective was to describe the independent association of OSA and sleep quality with HRQOL in children with obesity. METHODS: This was a cross-sectional study of children with obesity at 2 tertiary care centers. Sleep quality and HRQOL were measured with the Pittsburgh Sleep Quality Index and Pediatric Quality of Life Inventory questionnaires, respectively. Multivariable regression models were created to evaluate associations between OSA and sleep quality with HRQOL. RESULTS: There were 98 children (median age 15.0 years, median body mass index z-score 3.8, 44% females). Among the study population, 49/98 (50%) children reported poor sleep quality, 41/98 (42%) children had OSA, and 52/98 (53%) children reported impaired HRQOL. Self-reported poor sleep quality was independently associated with reduced HRQOL, whereas the presence of OSA was not. Children with poor sleep quality had a reduced Pediatric Quality of Life Inventory score by 8.8 compared to children with good sleep quality (95% confidence interval, 2.6-14.9; P = .006), when adjusting for age, sex, body mass index z-score, attention-deficit/hyperactivity disorder, mood/anxiety disorder, and study site. CONCLUSIONS: In the current study of children with obesity, we found that HRQOL was more strongly associated with the self-reported experience of sleep than the presence of OSA. Clinicians should assess and optimize sleep quality as part of the evaluation for OSA in children with obesity. CITATION: Xiao L, Voutsas G, Ryan CM, Katz SL, Narang I. The association between sleep quality and obstructive sleep apnea with health-related quality of life in children with obesity. J Clin Sleep Med. 2023;19(11):1877-1883.

Evaluating symptoms and polysomnographic findings among male and female children with obesity with and without obstructive sleep apnea.

OBJECTIVE: Limited data regarding sex-based differences in the presentation and phenotype of obstructive sleep apnea (OSA) exists among children with obesity. The study objectives were to compare reported symptoms and polysomnogram (PSG) findings between children with obesity 1) with and without OSA and 2) males and females with OSA. PATIENTS/METHODS: This cross-sectional study included children with obesity, aged 8-18 years, with a diagnostic PSG between 2015 and 2021, referred for evaluating sleep-related breathing. Patient demographics, anthropometrics, and PSG data were recorded. Symptoms were evaluated using Epworth Sleepiness Scale and Pediatric Sleep Questionnaire. Pubertal staging was collected using Tanner Stage questionnaire. PSG parameters, symptoms and pubertal stage were compared between sexes with and without OSA. RESULTS: Of 148 children, 61 (41%) had OSA. Within the OSA group, 41/62 (69%) were male (p = 0.002). Males with OSA reported higher Pediatric Sleep Questionnaire scores compared to males without OSA (0.38 ± 0.2 vs 0.23 ± 0.1; p = 0.002). Males with OSA reported more trouble breathing (p = 0.04) and mouth breathing (p = 0.008) compared to females with OSA. Females with OSA showed longer sleep onset latency (45.8 ± 40.6 min vs 22.4 ± 26.7; p = 0.02) and higher supine obstructive-apnea hypopnea index (32.9 ± 31.1 vs 20.4 ± 18.4 events/hour; p = 0.02) compared to males with OSA. A significant interaction was found between male sex and waist-to-height ratio (ß = 15.34, R2 = 0.18, p = 0.05). CONCLUSIONS: Sex differences in symptoms and phenotype of OSA exist among children with obesity. Such information is beneficial for early diagnosis and management to mitigate adverse outcomes and comorbidities.

To Wear or Not Wear the Mask: Decline in Positive Airway Pressure Usage in Children with Sleep Disordered Breathing During the COVID-19 Pandemic.

Purpose: Positive airway pressure (PAP) therapy is an effective treatment prescribed to children with sleep disordered breathing (SDB); however, PAP adherence remains challenging. Given that COVID-19 pandemic continues to impact sleep and daily life, the aim of this study was to evaluate longitudinal trajectory of PAP usage in children during the COVID-19 pandemic. Patients and Methods: This was a retrospective study. Children aged 1-18 years with SDB prescribed PAP at The Hospital for Sick Children (Toronto, Canada) were evaluated for PAP adherence. Demographics, medical history and PAP adherence data during four consecutive 3-month time periods from December 2019 to December 2020 were collected. These four time periods included i) prior to COVID-19 lockdown, ii) during the first three months of lockdown, iii) summer and iv) return to school period. Percentage of days where PAP was used for ≥4 hours and average nightly usage of PAP were primary outcomes. Results: A total of 149 children (61.7% male, mean (±SD) age=12.8 ± 4.1 years, BMI (±SD) z-score=1.45±1.43) were enrolled. Compared to prior to lockdown, the median (IQR) of percentage of PAP usage ≥4 hours and average nightly usage of PAP declined significantly during the summer and return to school periods (p<0.001 for all). By the end of the return to school period, only 69/149 (46%) showed sustained PAP usage and 80/149 (54%) had decreased PAP usage. Obesity was a risk factor for a decline in PAP usage after returning to school (ß=-15.36, p=0.03). Conclusion: Compared to COVID-19 pre-pandemic PAP usage, there was a significant decline in PAP usage across COVID-19 pandemic. There is critical under usage of PAP in children diagnosed with SDB, resulting in an urgent need to address barriers to mitigate poor adherence to PAP long-term. Targeted strategies are required to optimize PAP adherence in children with SDB.

The efficacy of neurosurgical intervention on sleep-disordered breathing in pediatric patients with Chiari malformation type I.

OBJECTIVE: Chiari malformation type I (CM-I) involves the herniation of the cerebellar tonsils through the foramen magnum. CM-I is associated with both obstructive sleep apnea (OSA) and central sleep apnea (CSA) in children. The primary management of symptomatic CM-I remains surgical decompression. There is, however, a paucity of data evaluating the efficacy of decompression surgery on outcomes related to sleep-disordered breathing (SDB). The objective of this study was to evaluate SDB outcomes, specifically the need for respiratory support following decompression in pediatric patients with CM-I. METHODS: This was a retrospective chart review of all children diagnosed with CM-I when younger than 18 years of age who had polysomnography (PSG) studies pre- and postsurgery, between January 2008 and October 2018 at the Hospital for Sick Children in Toronto. Patient demographics, symptoms, PSG data, ongoing respiratory support, and surgical notes were recorded. Differences in PSG studies obtained pre- and postsurgery were compared using the Wilcoxon test for paired samples. RESULTS: A total of 15 children with 15 interventions met inclusion criteria with pre- and postsurgery PSG studies and were considered for statistical analysis. Of the 15 subjects included for analysis, preoperative OSA was present in 2 (13.3%), CSA in 5 (33.3%), mixed SDB (both OSA and CSA) in 4 (26.7%), and no significant SDB in 4 (26.7%). Postoperatively, OSA was present in 3 (20.0%), CSA in 4 (26.7%), mixed SDB in 0 (0%), and no significant SDB in 8 (53.3%). The presence of severe OSA decreased from 4/15 (26.7%) to 2/15 (13.3%) postoperatively, and severe CSA decreased from 5/15 (33.3%) to 2/15 (13.3%) postoperatively. Following decompression surgery, 7/15 subjects (46.7%) required positive airway pressure for management of their SDB. Overall, significant improvements were observed in a number of respiratory parameters following decompression including the following: the total apnea-hypopnea index (AHI) (17.5 ± 48.2 vs 6.1 ± 32.7 events/hour; p = 0.001), obstructive AHI (2.1 ± 16.1 vs 1.0 ± 6.6 events/hour; p = 0.005), central AHI (6.3 ± 48.9 vs 2.7 ± 33.0 events/hour; p = 0.005), and the desaturation index (16.7 ± 49.6 vs 3.8 ± 25.3; p = 0.001). CONCLUSIONS: Although decompression surgery led to a significant reduction in obstructive and central events, many children continued to have persistent SDB and required additional positive airway pressure therapy. This information is important and relevant for anticipatory guidance around decompression surgery and the necessity for respiratory support for the management of SDB in pediatric patients with CM-I.

Sleep-disordered breathing, respiratory patterns during wakefulness and functional capacity in pediatric patients with rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation syndrome.

OBJECTIVE: To characterize the clinical presentation of sleep-disordered breathing and respiratory patterns at rest and during a 6-min walk test (6MWT) in children with rapid-onset obesity, hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome. METHODS: Retrospective study of children with ROHHAD who had a diagnostic baseline polysomnography, daytime cardiorespiratory monitoring at rest and a 6MWT. Polysomnography data were also compared with body mass index-, age-, and sex-matched controls. RESULTS: Of the eight children with ROHHAD, all eight (100%) had obstructive sleep apnea (OSA) and 2/8 (25%) had nocturnal hypoventilation (NH) on their baseline polysomnography. Comparing the ROHHAD group to the control group, there were no significant differences in the median (interquartile range [IQR]) obstructive apnea-hypopnea index (11.1 [4.3-58.4] vs. 14.4 [10.3-23.3] events/h, respectively; p = .78). However, children with ROHHAD showed a significantly higher desaturation index compared to the control group (37.9 [13.7-59.8] vs. 14.7 [4.3-27.6] events/h; p = .05). While awake at rest, some children with ROHHAD experienced significant desaturations associated with central pauses. During the 6MWT, no significant desaturations were observed, but two children showed moderate functional limitation. CONCLUSIONS: Among children with ROHHAD, respiratory instability may be demonstrated by a significant number and severity of oxygen desaturations during sleep in the presence of OSA, with or without NH, and oxygen desaturations with central pauses at rest during wakefulness. Interestingly, during daily activities that require submaximal effort, children may not experience oxygen desaturations. Early recognition of respiratory abnormalities and targeted therapeutic interventions are important to limit associated morbidity and mortality in ROHHAD.

Positional device therapy for the treatment of positional obstructive sleep apnea in children: a pilot study.

BACKGROUND: There is a critical gap in identifying effective interventions for children with obstructive sleep apnea (OSA) who do not tolerate continuous positive airway pressure therapy. Positional OSA (POSA) is a common clinical phenotype whereby OSA occurs predominantly while sleeping in supine position. POSA may be amenable to treatment with a positional device, a belt worn around the chest with cushions on the back to prevent supine positioning, but no data exists in children. The primary aim of this study was to evaluate the efficacy of positional device therapy for the treatment of POSA in children. METHODS: This observational study included children aged 4-18 years with POSA and an obstructive apnea-hypopnea index (OAHI) ≥ 5 events/hour on baseline polysomnogram (PSG) who underwent a second PSG to evaluate the efficacy of a positional device. The primary outcome was the change in OAHI. RESULTS: Ten children were included (8 male, median age 11.2 years, median body mass index z-score 1.6). Compared to the baseline PSG, PSG data obtained while using a positional device showed a reduced median (interquartile range) OAHI (15.2 [8.3-25.6] versus 6.7 [1.0-13.7] events/hour respectively; p = 0.004) and percentage of total sleep time in supine position (54.4 [35.0-80.6]% versus 4.2 [1.1-25.2]% respectively; p = 0.04). Despite observed improvements in the oxygen desaturation index, these results were not statistically significant. SIGNIFICANCE AND CONCLUSIONS: In this novel pilot study, positional device therapy was effective for the treatment of POSA. Positional device therapy may potentially change clinical practice as a cost-efficient and non-invasive treatment option for POSA.

Positional obstructive sleep apnea in an obese pediatric population.

STUDY OBJECTIVES: Positional obstructive sleep apnea (POSA) is a phenotype of obstructive sleep apnea (OSA) where sleep-related obstructive events occur predominantly in the supine position. Limited knowledge exists regarding the presence of POSA in children with obesity. The study objective was to determine the prevalence of POSA while identifying factors associated with POSA in children with obesity. METHODS: This was a cross-sectional study of children with obesity, aged 8 to 18 years, with a diagnostic polysomnogram (PSG) between 2012 to 2019, who were referred for the evaluation of sleep-related breathing. POSA was defined as an overall obstructive apnea-hypopnea index (OAHI) ≥5 events/h and a supine OAHI to nonsupine OAHI ratio of ≥2. Patient demographics, anthropometrics, and PSG data were recorded. RESULTS: Of the 112 children with obesity with a diagnostic PSG, 43 (38%) had OSA. Among those with OSA, 25 of 43 (58%) had POSA (mean age: 14.6 ± 2.3 years; mean body mass index: 37.7 ± 7.6 kg/m²; 68% male) and 18 of 43 (42%) had non-POSA (mean age: 13.9 ± 2.8 years; mean body mass index: 37.9 ± 7.2 kg/m²; 78% male). Among those with POSA, 13 of 25 (52%) had mild OSA, 7 of 25 (28%) had moderate OSA, and 5 of 25 (20%) had severe OSA. No significant differences were found in age, sex, and anthropometric measures between POSA and non-POSA groups. Time spent in supine and nonsupine sleep did not differ significantly between groups. CONCLUSIONS: In children with obesity and OSA, POSA occurs frequently. Identifying POSA allows for potential targeted positional therapy for children with obesity.