Obstructive sleep apnoea (OSA) is characterised by partial or complete upper airway obstruction during sleep. Approximately 1% to 4% of children are affected by OSA, with adenotonsillar hypertrophy ...being the most common underlying risk factor. Surgical removal of enlarged adenoids or tonsils is the currently recommended first-line treatment for OSA due to adenotonsillar hypertrophy. Given the perioperative risk and an estimated recurrence rate of up to 20% following surgery, there has recently been an increased interest in less invasive alternatives to adenotonsillectomy. As the enlarged adenoids and tonsils consist of hypertrophied lymphoid tissue, anti-inflammatory drugs have been proposed as a potential non-surgical treatment option in children with OSA.
To assess the efficacy and safety of anti-inflammatory drugs for the treatment of OSA in children.
We identified trials from searches of the Cochrane Airways Group Specialised Register, CENTRAL and MEDLINE (1950 to 2019). For identification of ongoing clinical trials, we searched ClinicalTrials.gov and the World Health Organization (WHO) trials portal.
Randomised controlled trials (RCTs) comparing anti-inflammatory drugs against placebo in children between one and 16 years with objectively diagnosed OSA (apnoea/hypopnoea index (AHI) ≥ 1 per hour).
Two authors independently performed screening, data extraction, and quality assessment. We separately pooled results for the comparisons 'intranasal steroids' and 'montelukast' against placebo using random-effects models. The primary outcomes for this review were AHI and serious adverse events. Secondary outcomes included the respiratory disturbance index, desaturation index, respiratory arousal index, nadir arterial oxygen saturation, mean arterial oxygen saturation, avoidance of surgical treatment for OSA, clinical symptom score, tonsillar size, and adverse events.
We included five trials with a total of 240 children aged one to 18 years with mild to moderate OSA (AHI 1 to 30 per hour). All trials were performed in specialised sleep medicine clinics at tertiary care centres. Follow-up time ranged from six weeks to four months. Three RCTs (n = 137) compared intranasal steroids against placebo; two RCTs compared oral montelukast against placebo (n = 103). We excluded one trial from the meta-analysis since the patients were not analysed as randomised. We also had concerns about selective reporting in another trial. We are uncertain about the difference in AHI (MD -3.18, 95% CI -8.70 to 2.35) between children receiving intranasal corticosteroids compared to placebo (2 studies, 75 participants; low-certainty evidence). In contrast, children receiving oral montelukast had a lower AHI (MD -3.41, 95% CI -5.36 to -1.45) compared to those in the placebo group (2 studies, 103 participants; moderate-certainty evidence). We are uncertain whether the secondary outcomes are different between children receiving intranasal corticosteroids compared to placebo: desaturation index (MD -2.12, 95% CI -4.27 to 0.04; 2 studies, 75 participants; moderate-certainty evidence), respiratory arousal index (MD -0.71, 95% CI -6.25 to 4.83; 2 studies, 75 participants; low-certainty evidence), and nadir oxygen saturation (MD 0.59%, 95% CI -1.09 to 2.27; 2 studies, 75 participants; moderate-certainty evidence). Children receiving oral montelukast had a lower respiratory arousal index (MD -2.89, 95% CI -4.68 to -1.10; 2 studies, 103 participants; moderate-certainty evidence) and nadir of oxygen saturation (MD 4.07, 95% CI 2.27 to 5.88; 2 studies, 103 participants; high-certainty evidence) compared to those in the placebo group. We are uncertain, however, about the difference in desaturation index (MD -2.50, 95% CI -5.53 to 0.54; 2 studies, 103 participants; low-certainty evidence) between the montelukast and placebo group. Adverse events were assessed and reported in all trials and were rare, of minor nature (e.g. nasal bleeding), and evenly distributed between study groups. No study examined the avoidance of surgical treatment for OSA as an outcome.
There is insufficient evidence for the efficacy of intranasal corticosteroids for the treatment of OSA in children; they may have short-term beneficial effects on the desaturation index and oxygen saturation in children with mild to moderate OSA but the certainty of the benefit on the primary outcome AHI, as well as the respiratory arousal index, was low due to imprecision of the estimates and heterogeneity between studies. Montelukast has short-term beneficial treatment effects for OSA in otherwise healthy, non-obese, surgically untreated children (moderate certainty for primary outcome and moderate and high certainty, respectively, for two secondary outcomes) by significantly reducing the number of apnoeas, hypopnoeas, and respiratory arousals during sleep. In addition, montelukast was well tolerated in the children studied. The clinical relevance of the observed treatment effects remains unclear, however, because minimal clinically important differences are not yet established for polysomnography-based outcomes in children. Long-term efficacy and safety data on the use of anti-inflammatory medications for the treatment of OSA in childhood are still not available. In addition, patient-centred outcomes like concentration ability, vigilance, or school performance have not been investigated yet. There are currently no RCTs on the use of other kinds of anti-inflammatory medications for the treatment of OSA in children. Future RCTs should investigate sustainability of treatment effects, avoidance of surgical treatment for OSA, and long-term safety of anti-inflammatory medications for the treatment of OSA in children and include patient-centred outcomes.
Children with special health care needs (SHCN) due to a chronic health condition perform more poorly at school compared to their classmates. There is still little knowledge on the causal pathways and ...which factors could be targeted by interventions. We, therefore, investigated school absenteeism in children with SHCN compared to their peers.
This study was based on data from the German population-based prospective cohort study ikidS (German for: I will start school). Children with SHCN were identified by the Children with Special Health Care Needs screener that captures five consequences of physical or mental chronic health conditions: (1) use or need of prescription medication, (2) above average use or need of medical, mental health, or educational services, (3) functional limitations compared with others of the same age, (4) use or need of specialized therapies, and (5) treatment or counseling for emotional, behavioral, or developmental problems. School absenteeism was defined as days absent from school due to illness during first grade and was reported by classroom teachers. Associations between SHCN consequences and school absenteeism were investigated by negative binomial regression models. Effect estimates were adjusted for confounding variables identified by a causal framework and directed acyclic graphs.
1,921 children (mean age at follow-up 7.3 years, standard deviation 0.3; 49% females) were included; of these, 14% had SHCN. Compared to their classmates, children with SHCN had more days absent (adjusted rate ratio: 1.37; 95% confidence interval 1.16, 1.62). The effect was strongest among children with i) functional limitations, ii) treatment or counseling for emotional, behavioral, or developmental problems, and iii) those who experienced two or more SHCN consequences.
Children with SHCN have higher school absenteeism, which could-at least partly-explain their poorer school performance and lower educational attainment. SHCN-specific targeted interventions may reduce the adverse effects of SHCN on educational outcomes in children.
Sleep-disordered breathing is associated with impaired attention and neurocognitive deficits. We assessed the association of snoring and intermittent hypoxia with poor academic performance in third ...grade school children (1,144 children). Snoring frequency and intermittent hypoxia were investigated using parental questionnaire and nocturnal home pulse oximetry. Intermittent hypoxia was specified as desaturation events of 90% or less pulse oximeter saturation. Poor academic performance was defined as grade 4-6 on a six-point scale (i.e., approximately the lowest quintile grades) in mathematics, science, reading, spelling, and/or handwriting in the most recent school report. Snoring "always" was significantly associated with poor academic performance in mathematics (odds ratio; 95% confidence interval: 3.6; 1.3-10.1), science (4.3; 1.3-14.6), and spelling (3.5; 1.2-10.3). Snoring "frequently" was also significantly associated with poor academic performance in mathematics (2.4; 1.3-4.7) and spelling (2.0; 1.04-3.8). A significant relationship between snoring and poor academic performance was also found in children without intermittent hypoxia, whereas intermittent hypoxia did not show an independent association with poor academic performance. Thus, habitual snoring (i.e., snoring frequently or always) was associated with poor academic performance in these primary school children.
Aim
Children with special health care needs (SHCN) perform more poorly at school compared to their classmates. Specific causal pathways have not yet been extensively studied. Therefore, we ...investigated teacher‐rated global attention, an important prerequisite for educational attainment, in children with SHCN.
Methods
Data of a population‐based prospective cohort study, which recruited preschool children from the Mainz‐Bingen area, Germany, were analysed. Children with SHCN were identified by the Children with Special Health Care Needs screening tool. In 2016, global attention was reported by teachers at the end of first grade (mean age: 7.3 years) on a 5‐point rating scale ranging from −2 through +2. Associations between SHCN consequences and teacher‐rated attention were estimated by linear mixed models, adjusted for confounding variables.
Results
We included 1921 children (51% males); of these, 14% had SHCN. Compared to their classmates, children with SHCN had poorer teacher‐rated attention scores (adjusted mean difference: −0.35, 95% CI: −0.52 to −0.17). The effect was strongest among children with treatment or counselling for mental health problems or functional limitations. The effect remained after excluding children with attention deficit hyperactivity disorder from the analysis.
Conclusion
Children with SHCN showed more teacher‐rated attention problems, which could explain their lower educational attainment.
Sleep-disordered breathing is associated with impaired behavior and poor academic performance in children. We aimed to determine the extent of behavioral problems in snoring children, clarify the ...role of intermittent hypoxia, and test the reversibility of impaired behavior and poor academic performance.
In 1144 children, habitual snoring (HS; snoring frequently or always) and impaired behavior were assessed using parental questionnaires. Intermittent hypoxia (ie, presence of > or =5 arterial oxygen desaturations by > or =4% or > or =1 desaturation to < or =90%) was investigated with pulse oximetry. Poor academic performance (grade 4-6 on a 6-point scale in mathematics, science, or spelling) was based on the last school report. HS, impaired behavior, and academic performance were reevaluated after 1 year. Adjusted odds ratios (ORs) were calculated using unconditional logistic regression.
HS was significantly associated with hyperactive (OR: 2.4) and inattentive behavior (OR: 4.0), daytime tiredness (OR: 7.1), and sleepiness (OR: 2.6-4.8). These associations were independent of intermittent hypoxia. HS was also significantly associated with bad conduct (OR: 2.8), emotional symptoms (OR: 5.5), and peer problems (OR: 9.7). At follow-up, hyperactive and inattentive behavior but not academic success had significantly improved in children in whom HS had ceased.
We suggest that impaired behavior is a key feature of HS independent of intermittent hypoxia and improves when HS ceases.
To evaluate whether anterior segment anatomy and axial length are associated with prematurity and perinatal factors in adults.
The Gutenberg Prematurity Eye Study examined adults born preterm and ...term aged 18-52 years. All participants underwent a prospective ophthalmic examination (optical biometry via a LenStar 900, Haag-Streit) in Germany. The associations between gestational age (GA), birth weight (BW) and BW percentile, retinopathy of prematurity (ROP) occurrence, ROP treatment and other perinatal factors with the main outcome measures were evaluated by univariate and multivariable linear regression analyses. Main outcome measures were corneal radius, white-to-white distance, anterior chamber depth, lens thickness and axial length.
The study involved 861 eyes of 438 preterm and full-term individuals (aged 28.6±8.7 years, 245 females,). After adjustment for age and gender, a steeper corneal radius was associated with lower GA (B=0.02; p<0.001) and a lower BW percentile (B=0.003; p<0.001). A smaller white-to-white distance was linked to lower GA (B=0.02; p<0.001), a lower BW percentile (B=0.004; p<0.001) and postnatal ROP occurrence (B=-0.26; p<0.001). Decreased axial length was associated with lower GA at birth (B=0.05; p=0.002) and pre-eclampsia (B=-0.34; p=0.015). ROP-treated eyes had a shallower anterior chamber depth (B=-0.63; p=0.001) and increased lens thickness (B=0.64, p<0.001).
Our analyses in adults demonstrate that the corneal morphology is influenced by GA and BW percentile, while the anterior chamber depth and lens thickness are affected by ROP treatment, namely laser therapy and cryotherapy. The present study highlights that perinatal factors lead to lifelong sequelae of ocular shape.
It has been suggested that habitual snoring (HS) has adverse health outcomes in children. We aimed to identify risk factors for HS and determine its natural history in primary school children.
...Cross-sectional, population-based cohort study.
Twenty-seven primary schools located within the city limits of Hannover, Germany.
Third-grade primary school children.
Snoring frequency and potential risk factors were investigated using parental questionnaires. Unadjusted and adjusted odds ratios (ORs) for HS and their 95% confidence intervals (CIs) were calculated. One year after the initial contact, snoring status was re-evaluated in habitual snorers. In total, 1,760 children were contacted, and 1,144 parents and their children (49% were girls) agreed to participate and returned a completed questionnaire. A body mass index ≥ 90th percentile (OR, 3.5; 95% CI, 1.8 to 7.1), low maternal education (OR, 2.3; 95% CI, 1.1 to 4.7), regular daytime mouth breathing (OR, 7.4; 95% CI, 3.5 to 15.6), and a higher frequency of sore throats (OR, 17.6; 95% CI, 6.4 to 48.8) were independent risk factors for HS. Parental smoking and frequent infections were significantly but not independently associated with HS. The association of low maternal education and HS was higher in boys (OR, 4.4; 95% CI, 1.5 to 13.6; vs OR, 1.2; 95% CI, 0.4 to 3.6), while that of sore throats and HS was higher in girls (OR, 52.7; 95% CI, 6.0 to 460.2; vs OR, 13.3; 95% CI, 3.0 to 58.5). At follow-up, 39 of 80 eligible habitual snorers (48.8%) still snored regularly. Children who continued to snore differed significantly in maternal education, household smoking, snoring loudness, and prior ear, nose, throat surgery from those who had ceased to snore habitually.
Socioeconomic status, obesity, signs of nasal obstruction, and pharyngeal problems were independent risk factors for HS in these primary school children. The expression of HS varied considerably over time.
Children with chronic health conditions may perform poorer at school. Associations may be confounded by numerous social factors. We aimed to estimate the effects of a chronic health condition on ...overall school performance in first graders with an emphasis on rigorous adjustment for potential confounders.
A population-based cohort study was performed in the area of Mainz-Bingen (Germany). In 2015 all preschoolers were approached and the presence of a chronic health condition was assessed by parental questionnaires and preschool health examination data. The identification of a chronic health condition was based on special health care needs and presence of a doctor's diagnosis out of 24 school-relevant diseases. At the end of the first school year, overall school performance was assessed by teachers and rated on a 5-item scale ranging from -10 to +10.
Of 3683 children approached, 2003 were enrolled. Overall school performance was available for 1462 children (51% boys). Of these, 52% suffered from a chronic health condition. Compared to children without a chronic health condition, children with special health care needs (15%) performed worse at school (adjusted mean difference: -0.95, 95% CI: -1.55; -0.35, P = 0.002). Children with a doctor's diagnosis but without special health care needs (37%) did not perform worse at school. The effect was further analysed considering the extent of special health care needed.
Chronic health conditions affect overall school performance early in primary school. To identify academically at-risk children, a chronic health condition identification based on special health care needs may be used.
To explore differences in the relationship between gestational age (GA) and birth weight (BW) percentile and ocular geometry between males and females.PurposeTo explore differences in the ...relationship between gestational age (GA) and birth weight (BW) percentile and ocular geometry between males and females.The Gutenberg Prematurity Eye Study involved a prospective ophthalmic examination of adults, aged 18 to 52 years, who were born preterm or at term, in Germany. The associations between GA and BW percentile on the main outcome measures were evaluated by uni- and multivariable linear regression analyses. The main outcome measures were central corneal thickness, corneal radius, anterior chamber depth, lens thickness, posterior segment length, and central foveal thickness. Potential sex-specific differences and an effect modification by sex were analyzed.MethodsThe Gutenberg Prematurity Eye Study involved a prospective ophthalmic examination of adults, aged 18 to 52 years, who were born preterm or at term, in Germany. The associations between GA and BW percentile on the main outcome measures were evaluated by uni- and multivariable linear regression analyses. The main outcome measures were central corneal thickness, corneal radius, anterior chamber depth, lens thickness, posterior segment length, and central foveal thickness. Potential sex-specific differences and an effect modification by sex were analyzed.This study involved 438 participants (245 females, 193 males) with an average age of 28.6 ± 8.7 years. In female participants, central foveal thickness was negatively associated with a higher GA (B = -2.99; P < 0.001). Similarly, male participants also demonstrated a negative association between central foveal thickness and GA (B = -4.27; P < 0.001). The multivariable model with effect modification revealed that the central foveal thickness was thicker with lower GA. There was an association between the effect modification of GA with sex and central foveal thickness, demonstrating a more pronounced effect of GA on central foveal thickness in male participants (B = 1.29; P = 0.04).ResultsThis study involved 438 participants (245 females, 193 males) with an average age of 28.6 ± 8.7 years. In female participants, central foveal thickness was negatively associated with a higher GA (B = -2.99; P < 0.001). Similarly, male participants also demonstrated a negative association between central foveal thickness and GA (B = -4.27; P < 0.001). The multivariable model with effect modification revealed that the central foveal thickness was thicker with lower GA. There was an association between the effect modification of GA with sex and central foveal thickness, demonstrating a more pronounced effect of GA on central foveal thickness in male participants (B = 1.29; P = 0.04).This study identified a sex-specific correlation between lower GA and thicker central foveal thickness, suggesting differences in the developmental trajectory of this biometric parameter concerning GA. A thicker central foveal thickness might affect the visual acuity of individuals born preterm in adulthood, with a more pronounced impact in males and a potential predisposition to age-related diseases later in life. Sex did not influence the association of GA or BW percentile to other ocular geometric parameters.ConclusionsThis study identified a sex-specific correlation between lower GA and thicker central foveal thickness, suggesting differences in the developmental trajectory of this biometric parameter concerning GA. A thicker central foveal thickness might affect the visual acuity of individuals born preterm in adulthood, with a more pronounced impact in males and a potential predisposition to age-related diseases later in life. Sex did not influence the association of GA or BW percentile to other ocular geometric parameters.
To assess the extent of perceived shared decision making (SDM) with parents of pediatric patients and to examine its association with characteristics of patients, professionals, and healthcare ...facilities.
Parents of pediatric patients (n = 4383) were recruited in 15 social pediatric centers in Germany and provided information on perceived SDM (binary CollaboRATEpediatric score: optimal versus suboptimal extent of SDM), child age and sex, type of impairment, appointment, and healthcare professional present at the appointment. Organizational characteristics were assessed in a cross-sectional survey of staff at the study sites.
Overall, 58.4% of parents reported an optimal extent of SDM. The optimal extent of SDM was more likely reported by parents of girls (OR=1.27, p < 0.001) and children with physical (as opposed to cognitive and combined) impairments (OR=1.30, p = 0.006), and after appointments attended by allied health professionals (OR=1.28, p = 0.004). In addition, parents in facilities receiving financing in addition to compensation by statutory health insurance funds were less likely to report an optimal extent of perceived SDM.
While SDM with parents was mostly related to individual characteristics of children and professionals at appointments, organizational characteristics seemed less relevant in our study.
Staff should be made aware of lower SDM with parents of boys, older children, and those with cognitive impairments, and trained to improve the SDM in these groups.
•Approximately 60% of parents reported an optimal extent of perceived SDM.•Parents of girls were more likely to report an optimal extent of SDM.•Parents of children ≥7 years were less likely to report an optimal extent of SDM.•Organizational characteristics were mostly not related to perceived SDM with parents.
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