Abstract
Obstructive sleep apnea syndrome (OSAS) is a common pediatric disorder characterized by recurrent events of partial or complete upper airway obstruction during sleep which result in abnormal ventilation and sleep pattern. OSAS in children is associated with neurobehavioral deficits and cardiovascular morbidity which highlights the need for prompt recognition, diagnosis, and treatment. The purpose of this state-of-the-art review is to provide an update on the evaluation and management of children with OSAS with emphasis on children with complex medical comorbidities and those with residual OSAS following first-line treatment. Proposed treatment strategies reflecting recommendations from a variety of professional societies are presented. All children should be screened for OSAS and those with typical symptoms (e.g., snoring, restless sleep, and daytime hyperactivity) or risk factors (e.g., neurologic, genetic, and craniofacial disorders) should undergo further evaluation including referral to a sleep specialist or pediatric otolaryngologist and overnight polysomnography, which provides a definitive diagnosis. A cardiology and/or endocrinology evaluation should be considered in high-risk children. For the majority of children, first-line treatment is tonsillectomy with or without adenoidectomy; however, some children exhibit multiple levels of airway obstruction and may require additional evaluation and management. Anti-inflammatory medications, weight loss, and oral appliances may be appropriate in select cases, particularly for mild OSAS. Following initial treatment, all children should be monitored for residual symptoms and polysomnography may be repeated to identify persistent disease, which can be managed with positive airway pressure ventilation and additional surgical approaches if required.
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References
Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Sheldon SH, Spruyt K, Ward SD, Lehmann C, Shiffman RN (2012) Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 130:576–584. https://doi.org/10.1542/peds.2012-1671
Muzumdar H, Arens R (2013) Physiological effects of obstructive sleep apnea syndrome in childhood. Respir Physiol Neurobiol 188:370–382. https://doi.org/10.1016/j.resp.2013.05.006
Lumeng JC, Chervin RD (2008) Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc 5:242–252. https://doi.org/10.1513/pats.200708-135mg
Arens R, Muzumdar H (2010) Childhood obesity and obstructive sleep apnea syndrome. J Appl Physiol 108:436–444. https://doi.org/10.1152/japplphysiol.00689.2009
Tan H-L, Gozal D, Kheirandish-Gozal L (2013) Obstructive sleep apnea in children: a critical update. Nat Sci Sleep. https://doi.org/10.2147/nss.s51907
Smith DF, Amin RS (2019) OSA and cardiovascular risk in pediatrics. Chest 156:402–413. https://doi.org/10.1016/j.chest.2019.02.011
Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, Mitchell RB, Amin R, Katz ES, Arens R, Paruthi S, Muzumdar H, Gozal D, Thomas NH, Janice Ware DB, Snyder K, Elden L, Sprecher RC, Willging P, Jones D, Bent JP, Hoban T, Chervin RD, Ellenberg SS, Redline S (2013) A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 368:2366–2376. https://doi.org/10.1056/NEJMoa1215881
Reuveni H, Simon T, Tal A, Elhayany A, Tarasiuk A (2002) Health care services utilization in children with obstructive sleep apnea syndrome. Pediatrics 110:68–72. https://doi.org/10.1542/peds.110.1.68
Arens R, Marcus CL (2004) Pathophysiology of upper airway obstruction: A developmental perspective. Sleep 27:997–1019. https://doi.org/10.1093/sleep/27.5.997
Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC (2019) Clinical Practice guideline: tonsillectomy in children (update). Otolaryngol Neck Surg 160:S1–S42. https://doi.org/10.1177/0194599818801757
Friedman M, Wilson M, Lin HC, Chang HW (2009) Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 140:800–808. https://doi.org/10.1016/j.otohns.2009.01.043
Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J, Simakajornboon N, Kaditis AG, Splaingard D, Splaingard M, Brooks LJ, Marcus CL, Sin S, Arens R, Verhulst SL, Gozal D (2010) Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med 182:676–683. https://doi.org/10.1164/rccm.200912-1930OC
Tauman R, Gulliver TE, Krishna J, Montgomery-Downs HE, O’Brien LM, Ivanenko A, Gozal D (2006) Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr 149:803–808. https://doi.org/10.1016/j.jpeds.2006.08.067
Carroll JL, McColley SA, Marcus CL, Curtis S, Loughlin GM (1995) Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest 108:610–618. https://doi.org/10.1378/chest.108.3.610
Certal V, Catumbela E, Winck JC, Azevedo I, Teixeira-Pinto A, Costa-Pereira A (2012) Clinical assessment of pediatric obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope 122:2105–2114. https://doi.org/10.1002/lary.23465
Gozal D, Wang M, Pope DW (2001) Objective sleepiness measures in pediatric obstructive sleep apnea. Pediatrics 108:693–697. https://doi.org/10.1542/peds.108.3.693
Rosen CL (1999) Clinical features of obstructive sleep apnea hypoventilation syndrome in otherwise healthy children. Pediatr Pulmonol 27:403–409. https://doi.org/10.1002/(SICI)1099-0496(199906)27:6%3c403:AID-PPUL7%3e3.0.CO;2-8
Perfect MM, Archbold K, Goodwin JL, Levine-Donnerstein D, Quan SF (2013) Risk of behavioral and adaptive functioning difficulties in youth with previous and current sleep disordered breathing. Sleep. https://doi.org/10.5665/sleep.2536
O’Brien LM, Mervis CB, Holbrook CR, Bruner JL, Smith NH, McNally N, McClimment MC, Gozal D (2004) Neurobehavioral correlates of sleep-disordered breathing in children. J Sleep Res 13:165–172. https://doi.org/10.1111/j.1365-2869.2004.00395.x
Hunter SJ, Gozal D, Smith DL, Philby MF, Kaylegian J, Kheirandish-Gozal L (2016) Effect of sleep-disordered breathing severity on cognitive performance measures in a large community cohort of young school-aged children. Am J Respir Crit Care Med 194:739–747. https://doi.org/10.1164/rccm.201510-2099OC
Brodsky L (1989) Modern assessment of tonsils and adenoids. Pediatr Clin N Am 36:1551–1569. https://doi.org/10.1016/S0031-3955(16)36806-7
Marcus CL, Greene MG, Carroll JL (1998) Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med 157:1098–1103. https://doi.org/10.1164/ajrccm.157.4.9704080
Amin RS, Carroll JL, Jeffries JL, Grone C, Bean JA, Chini B, Bokulic R, Daniels SR (2004) Twenty-four-hour ambulatory blood pressure in children with sleep-disordered breathing. Am J Respir Crit Care Med 169:950–956. https://doi.org/10.1164/rccm.200309-1305oc
Ingram DG, Singh AV, Ehsan Z, Birnbaum BF (2017) Obstructive sleep apnea and pulmonary hypertension in children. Paediatr Respir Rev 23:33–39. https://doi.org/10.1016/j.prrv.2017.01.001
Berry RB, Albertario CL, Harding SM (2018) The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, version 2.5. American Academy of Sleep Medicine, Darien
American Academy of Sleep Medicine (2014) International classification of sleep disorders, 3rd edn. American Academy of Sleep Medicine, Darien
Isaiah A, Hamdan H, Johnson RF, Naqvi K, Mitchell RB (2017) Very severe obstructive sleep apnea in children: outcomes of adenotonsillectomy and risk factors for persistence. Otolaryngol Head Neck Surg (United States) 157:128–134. https://doi.org/10.1177/0194599817700370
Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW, Kuhar S, Mitchell RB, Seidman MD, Sheldon SH, Jones S, Robertson P (2011) Clinical practice guideline: polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Neck Surg 145:S1–S15. https://doi.org/10.1177/0194599811409837
Brouilette R, Hanson D, David R, Klemka L, Anna S, Fernbach S, Hunt C (1984) A diagnostic approach to suspected obstructive sleep apnea in children. J Pediatr 105:10–14. https://doi.org/10.1016/S0022-3476(84)80348-0
Chervin RD, Weatherly RA, Garetz SL, Ruzicka DL, Giordani BJ, Hodges EK, Dillon JE, Guire KE (2007) Pediatric sleep questionnaire: prediction of sleep apnea and outcomes. Arch Otolaryngol Head Neck Surg 133:216–222. https://doi.org/10.1001/archotol.133.3.216
Franco RA, Rosenfeld RM, Rao M (2000) Quality of life for children with obstructive sleep apnea. Otolaryngol Neck Surg 123:9–16. https://doi.org/10.1067/mhn.2000.105254
Patel AP, Meghji S, Phillips JS (2019) Accuracy of clinical scoring tools for the diagnosis of pediatric obstructive sleep apnea. Laryngoscope. https://doi.org/10.1002/lary.28146
Rosen CL, Wang R, Taylor HG, Marcus CL, Katz ES, Paruthi S, Arens R, Muzumdar H, Garetz SL, Mitchell RB, Jones D, Weng J, Ellenberg S, Redline S, Chervin RD (2015) Utility of symptoms to predict treatment outcomes in obstructive sleep apnea syndrome. Pediatrics 135:e662–e671. https://doi.org/10.1542/peds.2014-3099
Villa MP, Paolino MC, Castaldo R, Vanacore N, Rizzoli A, Miano S, Del Pozzo M, Montesano M (2013) Sleep clinical record: an aid to rapid and accurate diagnosis of paediatric sleep disordered breathing. Eur Respir J 41:1355–1361. https://doi.org/10.1183/09031936.00215411
Certal V, Silva H, Carvalho C, Costa-Pereira A, Azevedo I, Winck J, Capasso R, Camacho M (2015) Model for prediction of pediatric OSA: proposal for a clinical decision rule. Laryngoscope 125:2823–2827. https://doi.org/10.1002/lary.25438
Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K, Harrod CG (2017) Clinical practice guideline OSA american academy. J Clin Sleep Med 13:479–504. https://doi.org/10.5664/jcsm.6506
Kirk V, Baughn J, D’Andrea L, Friedman N, Galion A, Garetz S, Hassan F, Wrede J, Harrod CG, Malhotra RK (2017) American academy of sleep medicine position paper for the use of a home sleep apnea test for the diagnosis of OSA in children. J Clin Sleep Med 13:1199–1203. https://doi.org/10.5664/jcsm.6772
Brouillette RT, Morielli A, Leimanis A, Waters KA, Luciano R, Ducharme FM (2000) Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics 105:405–412. https://doi.org/10.1542/peds.105.2.405
Owen GO, Canter RJ (1996) Overnight pulse oximetry in normal children and in children undergoing adenotonsillectomy. Clin Otolaryngol Allied Sci 21:59–65. https://doi.org/10.1111/j.1365-2273.1996.tb01026.x
Hornero R, Kheirandish-Gozal L, Gutiérrez-Tobal GC, Philby MF, Alonso-Álvarez ML, Alvarez D, Dayyat EA, Xu Z, Huang YS, Kakazu MT, Li AM, Van Eyck A, Brockmann PE, Ehsan Z, Simakajornboon N, Kaditis AG, Vaquerizo-Villar F, Sedano AC, Capdevila OS, Von Lukowicz M, Terán-Santos J, Del CF, Poets CF, Ferreira R, Bertran K, Zhang Y, Schuen J, Verhulst S, Gozal D (2017) Nocturnal oximetry-based evaluation of habitually snoring children. Am J Respir Crit Care Med 196:1591–1598. https://doi.org/10.1164/rccm.201705-0930OC
Fujioka M, Young LW, Girdany BR (1979) Radiographic evaluation of adenoidal size in children: adenoidal-nasopharyngeal ratio. Am J Roentgenol 133:401–404. https://doi.org/10.2214/ajr.133.3.401
Kawashima S, Niikuni N, Chia-hung L, Takahasi Y, Kohno M, Nakajima I, Akasaka M, Sakata H, Akashi S (2000) Cephalometric comparisons of craniofacial and upper airway structures in young children with obstructive sleep apnea syndrome. Ear Nose Throat J 79:499–502. https://doi.org/10.1177/014556130007900708
Arens R, McDonough JM, Costarino AT, Mahboubi S, Tayag-Kier CE, Maislin G, Schwab RJ, Pack AI (2001) Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 164:698–703. https://doi.org/10.1164/ajrccm.164.4.2101127
Gibson SE, Strife JL, Myer CM, O’Connor DM (1996) Sleep fluoroscopy for localization of upper airway obstruction in children. Ann Otol Rhinol Laryngol 105:678–683. https://doi.org/10.1177/000348949610500902
Slaats MA, Van Hoorenbeeck K, Van Eyck A, Vos WG, De Backer JW, Boudewyns A, De Backer W, Verhulst SL (2015) Upper airway imaging in pediatric obstructive sleep apnea syndrome. Sleep Med Rev 21:59–71. https://doi.org/10.1016/j.smrv.2014.08.001
Fregosi RF, Quan SF, Kaemingk KL, Morgan WJ, Goodwin JL, Cabrera R, Gmitro A (2003) Sleep-disordered breathing, pharyngeal size and soft tissue anatomy in children. J Appl Physiol 95:2030–2038. https://doi.org/10.1152/japplphysiol.00293.2003
Arens R, Sin S, McDonough JM, Palmer JM, Dominguez T, Meyer H, Wootton DM, Pack AI (2005) Changes in upper airway size during tidal breathing in children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 171:1298–1304. https://doi.org/10.1164/rccm.200411-1597OC
Wootton DM, Sin S, Luo H, Yazdani A, McDonough JM, Wagshul ME, Isasi CR, Arens R (2016) Computational fluid dynamics upper airway effective compliance, critical closing pressure, and obstructive sleep apnea severity in obese adolescent girls. J Appl Physiol 121:925–931. https://doi.org/10.1152/japplphysiol.00190.2016
Shott SR, Donnelly LF (2004) Cine magnetic resonance imaging: Evaluation of persistent airway obstruction after tonsil and adenoidectomy in children with down syndrome. Laryngoscope 114:1724–1729. https://doi.org/10.1097/00005537-200410000-00009
Socarras MA, Landau BP, Durr ML (2019) Diagnostic techniques and surgical outcomes for persistent pediatric obstructive sleep apnea after adenotonsillectomy: A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol 121:179–187. https://doi.org/10.1016/j.ijporl.2019.02.030
Wilcox LJ, Bergeron M, Reghunathan S, Ishman SL (2017) An updated review of pediatric drug-induced sleep endoscopy. Laryngosc Investig Otolaryngol 2:423–431. https://doi.org/10.1002/lio2.118
He S, Peddireddy NS, Smith DF, Duggins AL, Heubi C, Shott SR, Ishman SL (2018) Outcomes of drug-induced sleep endoscopy-directed surgery for pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg 158:559–565. https://doi.org/10.1177/0194599817740332
Esteller E, Villatoro JC, Agüero A, Matiñó E, Lopez R, Aristimuño A, Nuñez V, Díaz-Herrera MA (2019) Outcome of drug-induced sleep endoscopy-directed surgery for persistent obstructive sleep apnea after adenotonsillar surgery. Int J Pediatr Otorhinolaryngol 120:118–122. https://doi.org/10.1016/j.ijporl.2019.02.004
Drager LF, Togeiro SM, Polotsky VY, Lorenzi-Filho G (2013) Obstructive sleep apnea: a cardiometabolic risk in obesity and the metabolic syndrome. J Am Coll Cardiol 62:569–576. https://doi.org/10.1016/j.jacc.2013.05.045
Chinnadurai S, Jordan AK, Sathe NA, Fonnesbeck C, McPheeters ML, Francis DO (2017) Tonsillectomy for obstructive sleep-disordered breathing: a meta-analysis. Pediatrics 139:e20163491. https://doi.org/10.1542/peds.2016-3491
Sulman CG (2014) Pediatric sleep surgery. Front Pediatr 2:51. https://doi.org/10.3389/fped.2014.00051
Parikh SR, Archer S, Ishman SL, Mitchell RB (2019) why is there no statement regarding partial intracapsular tonsillectomy (tonsillotomy) in the new guidelines? Otolaryngol Head Neck Surg 160:213–214. https://doi.org/10.1177/0194599818810507
Mukhatiyar P, Nandalike K, Cohen HW, Sin S, Gangar M, Bent JP, Arens R (2016) Intracapsular and extracapsular tonsillectomy and adenoidectomy in pediatric obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg 142:25–31. https://doi.org/10.1001/jamaoto.2015.2603
Imanguli M, Ulualp SO (2016) Risk factors for residual obstructive sleep apnea after adenotonsillectomy in children. Laryngoscope 126:2624–2629. https://doi.org/10.1002/lary.25979
Bluher AE, Ishman SL, Baldassari CM (2019) Managing the child with persistent sleep apnea. Otolaryngol Clin N Am 52:891–901. https://doi.org/10.1016/j.otc.2019.06.004
Com G, Carroll JL, Tang X, Melguizo MS, Bower C, Jambhekar S (2015) Characteristics and surgical and clinical outcomes of severely obese children with obstructive sleep apnea. J Clin Sleep Med 11:467–474. https://doi.org/10.5664/jcsm.4608
Ulualp SO (2014) Modified expansion sphincter pharyngoplasty for treatment of children with obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg 140:817–822. https://doi.org/10.1001/jamaoto.2014.1329
Cheng PW, Fang KM, Su HW, Huang TW (2012) Improved objective outcomes and quality of life after adenotonsillectomy with inferior turbinate reduction in pediatric obstructive sleep apnea with inferior turbinate hypertrophy. Laryngoscope 122:2850–2854. https://doi.org/10.1002/lary.23590
Grindle CR, Murray RC, Chennupati SK, Barth PC, Reilly JS (2011) Incidence of revision adenoidectomy in children. Laryngoscope 121:2128–2130. https://doi.org/10.1002/lary.22161
Noller MW, Guilleminault C, Gouveia CJ, Mack D, Neighbors CL, Zaghi S, Camacho M (2018) Mandibular advancement for pediatric obstructive sleep apnea: a systematic review and meta-analysis. J Cranio-Maxillofacial Surg 46:1296–1302. https://doi.org/10.1016/j.jcms.2018.04.027
Tahiri Y, Viezel-Mathieu A, Aldekhayel S, Lee J, Gilardino M (2014) The effectiveness of mandibular distraction in improving airway obstruction in the pediatric population. Plast Reconstr Surg 133:352–359. https://doi.org/10.1097/01.prs.0000438049.29258.a8
Wootten CT, Shott SR (2010) Evolving therapies to treat retroglossal and base-of-tongue obstruction in pediatric obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 136:983–987. https://doi.org/10.1001/archoto.2010.178
Song SA, Wei JM, Buttram J, Tolisano AM, Chang ET, Liu SYC, Certal V, Camacho M (2016) Hyoid surgery alone for obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope 126:1702–1708. https://doi.org/10.1002/lary.25847
Rizzi CJ, Amin JD, Isaiah A, Valdez TA, Jeyakumar A, Smart SE, Pereira KD (2017) Tracheostomy for severe pediatric obstructive sleep apnea: indications and outcomes. Otolaryngol Head Neck Surg (United States) 157:309–313. https://doi.org/10.1177/0194599817702369
Berry RB, Chediak A, Brown LK, Finder J, Gozal D, Iber C, Kushida CA, Morgenthaler T, Rowley JA, Davidson-Ward SL (2010) Best clinical practices for the sleep center adjustment of noninvasive positive pressure ventilation (NPPV) in stable chronic alveolar hypoventilation syndromes: NPPV titration task force of the American academy of sleep medicine. J Clin Sleep Med 6:491–509
Marcus CL, Rosen G, Ward SLD, Halbower AC, Sterni L, Lutz J, Stading PJ, Bolduc D, Gordon N (2006) Adherence to and effectiveness of positive airway pressure therapy in children with obstructive sleep apnea. Pediatrics 117:e442–e451. https://doi.org/10.1542/peds.2005-1634
Uong EC, Epperson M, Bathon SA, Jeffe DB (2007) Adherence to nasal positive airway pressure therapy among school-aged children and adolescents with obstructive sleep apnea syndrome. Pediatrics 120:e1203–e1211. https://doi.org/10.1542/peds.2006-2731
Haentjens P, Van Meerhaeghe A, Moscariello A, De Weerdt S, Poppe K, Dupont A, Velkeniers B (2007) The impact of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials. Arch Intern Med 167:757–765. https://doi.org/10.1001/archinte.167.8.757
Giles TL, Lasserson TJ, Smith BH, White J, Wright J, Cates CJ (2006) Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane database Syst Rev. https://doi.org/10.1002/14651858.CD001106.pub3
Jambhekar SK, Com G, Tang X, Pruss KK, Jackson R, Bower C, Carroll JL, Ward W (2013) Role of a respiratory therapist in improving adherence to positive airway pressure treatment in a pediatric sleep apnea clinic. Respir Care 58:2038–2044. https://doi.org/10.4187/respcare.02312
Kirk VG, O’Donnell AR (2006) Continuous positive airway pressure for children: a discussion on how to maximize compliance. Sleep Med Rev 10:119–127. https://doi.org/10.1016/j.smrv.2005.07.002
Pépin JL, Leger P, Veale D, Langevin B, Robert D, Lévy P (1995) Side effects of nasal continuous positive airway pressure in sleep apnea syndrome. Study of 193 patients in two French sleep centers. Chest 107:375–381. https://doi.org/10.1378/chest.107.2.375
Ahmad Z, Venus M, Kisku W, Rayatt SS (2013) A case series of skin necrosis following use of non invasive ventilation pressure masks. Int Wound J 10:87–90. https://doi.org/10.1111/j.1742-481X.2012.00948.x
Li KK, Riley RW, Guilleminault C (2000) An unreported risk in the use of home nasal continuous positive airway pressure and home nasal ventilation in children: mid-face hypoplasia. Chest 117:916–918. https://doi.org/10.1378/chest.117.3.916
Roberts SD, Kapadia H, Greenlee G, Chen ML (2016) Midfacial and dental changes associated with nasal positive airway pressure in children with obstructive sleep apnea and craniofacial conditions. J Clin Sleep Med 12:469–475. https://doi.org/10.5664/jcsm.5668
Fauroux B, Lavis J-F, Nicot F, Picard A, Boelle P-Y, Clément A, Vazquez M-P (2005) Facial side effects during noninvasive positive pressure ventilation in children. Intens Care Med 31:965–969. https://doi.org/10.1007/s00134-005-2669-2
Gudnadottir G, Ellegård E, Hellgren J (2018) Intranasal budesonide and quality of life in pediatric sleep-disordered breathing: a randomized controlled trial. Otolaryngol Head Neck Surg (United States) 158:752–759. https://doi.org/10.1177/0194599817742597
Kheirandish L, Goldbart AD, Gozal D (2006) Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing after tonsillectomy and adenoidectomy in children. Pediatrics. https://doi.org/10.1542/peds.2005-0795
Liming BJ, Ryan M, Mack D, Ahmad I, Camacho M (2019) Montelukast and nasal corticosteroids to treat pediatric obstructive sleep apnea: a systematic review and meta-analysis. Otolaryngol Head Neck Surg (United States) 160:594–602. https://doi.org/10.1177/0194599818815683
Kheirandish-Gozal L, Bhattacharjee R, Bandla HPR, Gozal D (2014) Antiinflammatory therapy outcomes for mild OSA in children. Chest 146:88–95. https://doi.org/10.1378/chest.13-2288
Villa MP, Malagola C, Pagani J, Montesano M, Rizzoli A, Guilleminault C, Ronchetti R (2007) Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med 8:128–134. https://doi.org/10.1016/j.sleep.2006.06.009
Pirelli P, Saponara M, Guilleminault C (2004) Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep 27:761–766. https://doi.org/10.1093/sleep/27.4.761
Villa MP, Bernkopf E, Pagani J, Broia V, Montesano M, Ronchetti R (2002) Randomized controlled study of an oral jaw-positioning appliance for the treatment of obstructive sleep apnea in children with malocclusion. Am J Respir Crit Care Med 165:123–127. https://doi.org/10.1164/ajrccm.165.1.2011031
Carvalho FR, Lentini-Oliveira DA, Prado LB, Prado GF, Carvalho LBC (2016) Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children. Cochrane database Syst Rev. https://doi.org/10.1002/14651858.CD005520.pub3
Shete MM, Stocks RMS, Sebelik ME, Schoumacher RA (2010) Effects of adeno-tonsillectomy on polysomnography patterns in down syndrome children with obstructive sleep apnea: a comparative study with children without Down syndrome. Int J Pediatr Otorhinolaryngol 74:241–244. https://doi.org/10.1016/j.ijporl.2009.11.006
Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G (1999) Risk factors for sleep-disordered breathing in children: associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med 159:1527–1532. https://doi.org/10.1164/ajrccm.159.5.9809079
Arens R, Sin S, Nandalike K, Rieder J, Khan UI, Freeman K, Wylie-Rosett J, Lipton ML, Wootton DM, McDonough JM, Shifteh K (2011) Upper airway structure and body fat composition in obese children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 183:782–787. https://doi.org/10.1164/rccm.201008-1249OC
Andersen IG, Holm JC, Homøe P (2016) Obstructive sleep apnea in obese children and adolescents, treatment methods and outcome of treatment - A systematic review. Int J Pediatr Otorhinolaryngol 87:190–197. https://doi.org/10.1016/j.ijporl.2016.06.017
Nandalike K, Shifteh K, Sin S, Strauss T, Stakofsky A, Gonik N, Bent J, Parikh SR, Bassila M, Nikova M, Muzumdar H, Arens R (2013) Adenotonsillectomy in obese children with obstructive sleep apnea syndrome: magnetic resonance imaging findings and considerations. Sleep 36:841–847. https://doi.org/10.5665/sleep.2708
Andersen IG, Holm JC, Homøe P (2019) Impact of weight-loss management on children and adolescents with obesity and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 123:57–62. https://doi.org/10.1016/j.ijporl.2019.04.031
Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silverstein JH, Yanovski JA (2017) Pediatric obesity-assessment, treatment, and prevention: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 102:709–757. https://doi.org/10.1210/jc.2016-2573
Scheffler P, Wolter NE, Narang I, Amin R, Holler T, Ishman SL, Propst EJ (2019) Surgery for obstructive sleep apnea in obese children: literature review and meta-analysis. Otolaryngol Head Neck Surg (United States) 160:985–992. https://doi.org/10.1177/0194599819829415
Lee CF, Lee CH, Hsueh WY, Lin MT, Kang KT (2018) Prevalence of obstructive sleep apnea in children with down syndrome: a meta-analysis. J Clin Sleep Med 14:867–875. https://doi.org/10.5664/jcsm.7126
Bull MJ, Saal HM, Braddock SR, Enns GM, Gruen JR, Perrin JM, Saul RA, Tarini BA, Hersh JH, Mendelsohn NJ, Hanson JW, Lloyd-Puryear MA, Musci TJ, Rasmussen SA, Downs SM, Spire P (2011) Clinical report—health supervision for children with down syndrome. Pediatrics 128:393–406. https://doi.org/10.1542/peds.2011-1605
Uong EC, McDonough JM, Tayag-Kier CE, Zhao H, Hasselgrove J, Mahboubi S, Schwab RJ, Pack AI, Arens R (2001) Magnetic resonance imaging of the upper airway in children with down syndrome. Am J Respir Crit Care Med 163:731–736. https://doi.org/10.1164/ajrccm.163.3.2004231
Fricke BL, Donnelly LF, Shott SR, Kalra M, Poe SA, Chini BA, Amin RS (2006) Comparison of lingual tonsil size as depicted on MR imaging between children with obstructive sleep apnea despite previous tonsillectomy and adenoidectomy and normal controls. Pediatr Radiol 36:518–523. https://doi.org/10.1007/s00247-006-0149-7
Donnelly LF, Shott SR, LaRose CR, Chini BA, Amin RS (2004) Causes of persistent obstructive sleep apnea despite previous tonsillectomy and adenoidectomy in children with down syndrome as depicted on static and dynamic cine MRI. Am J Roentgenol 183:175–181. https://doi.org/10.2214/ajr.183.1.1830175
Hawkins A, Langton-Hewer S, Henderson J, Tulloh RM (2011) Management of pulmonary hypertension in down syndrome. Eur J Pediatr 170:915–921. https://doi.org/10.1007/s00431-010-1378-1
Carskadon MA, Pueschel SM, Millman RP (1993) Sleep-disordered breathing and behavior in three risk groups: preliminary findings from parental reports. Child’s Nerv Syst 9:452–457. https://doi.org/10.1007/BF00393547
Breslin J, Spanò G, Bootzin R, Anand P, Nadel L, Edgin J (2014) Obstructive sleep apnea syndrome and cognition in down syndrome. Dev Med Child Neurol 56:657–664. https://doi.org/10.1111/dmcn.12376
Lal C, White DR, Joseph JE, Van Bakergem K, LaRosa A (2015) Sleep-disordered breathing in down syndrome. Chest 147:570–579. https://doi.org/10.1378/chest.14-0266
Farhood Z, Isley JW, Ong AA, Nguyen SA, Camilon TJ, LaRosa AC, White DR (2017) Adenotonsillectomy outcomes in patients with Down syndrome and obstructive sleep apnea. Laryngoscope 127:1465–1470. https://doi.org/10.1002/lary.26398
Akkina SR, Ma CC, Kirkham EM, Horn DL, Chen ML, Parikh SR (2018) Does drug induced sleep endoscopy-directed surgery improve polysomnography measures in children with down Syndrome and obstructive sleep apnea? Acta Otolaryngol 138:1009–1013. https://doi.org/10.1080/00016489.2018.1504169
Anderson ICW, Sedaghat AR, McGinley BM, Redett RJ, Boss EF, Ishman SL (2011) Prevalence and severity of obstructive sleep apnea and snoring in infants with Pierre Robin sequence. Cleft Palate-Craniofacial J 48:614–618. https://doi.org/10.1597/10-100
Kurian C, Ehsan Z (2019) Sleep and respiratory outcomes in neonates with Pierre Robin sequence: a concise review. Sleep Breath. https://doi.org/10.1007/s11325-019-01876-6
Hsieh ST, Woo AS (2019) Pierre Robin sequence. Clin Plast Surg 46:249–259. https://doi.org/10.1016/j.cps.2018.11.010
Staudt CB, Gnoinski WM, Peltomäki T (2013) Upper airway changes in Pierre Robin sequence from childhood to adulthood. Orthod Craniofacial Res 16:202–213. https://doi.org/10.1111/ocr.12019
Arens R, Muzumdar H (2010) Sleep, sleep disordered breathing, and nocturnal hypoventilation in children with neuromuscular diseases. Paediatr Respir Rev 11:24–30. https://doi.org/10.1016/j.prrv.2009.10.003
Aurora RN, Zak RS, Karippot A, Lamm CI, Morgenthaler TI, Auerbach SH, Bista SR, Casey KR, Chowdhuri S, Kristo DA, Ramar K (2011) Practice parameters for the respiratory indications for polysomnography in children. Sleep 34:379–388. https://doi.org/10.1093/sleep/34.3.379
Kaditis AG, Alvarez MLA, Boudewyns A, Alexopoulos EI, Ersu R, Joosten K, Larramona H, Miano S, Narang I, Trang H, Tsaoussoglou M, Vandenbussche N, Villa MP, Van WD, Weber S, Verhulst S (2016) Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J 47:69–94. https://doi.org/10.1183/13993003.00385-2015
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Bitners, A.C., Arens, R. Evaluation and Management of Children with Obstructive Sleep Apnea Syndrome. Lung 198, 257–270 (2020). https://doi.org/10.1007/s00408-020-00342-5
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DOI: https://doi.org/10.1007/s00408-020-00342-5