Positive Airway Pressure and Metabolic Markers in Children With Obstructive Sleep Apnea.

BACKGROUND: Increasing evidence suggests an association between childhood obstructive sleep apnea (OSA) and metabolic syndrome, with more research available on the potential impacts of positive airway pressure (PAP) on metabolic markers in children. The purpose of this systematic review is to provide a systematic synthesis of the evidence on the effect of PAP use on metabolic markers in children with OSA. METHODS: A search strategy with terms for "OSA" and metabolic markers in pediatrics was run to systematically assess 5 databases until August 26, 2022. Two reviewers independently screened eligible articles, extracted data, and conducted quality appraisal. Meta-analysis was done using random-effects models. Body mass index (BMI), glycemic, lipid, cardiovascular, and other metabolic and inflammatory markers were reported. RESULTS: Sixteen studies (N = 1,213) were included, 15 observational studies and 1 randomized controlled trial (RCT); most reported outcomes in children with obesity. Meta-analysis of 4 studies found no changes in BMI at median average follow-up of 12 months after PAP initiation. A reduction in heart rate and blood pressure parameters was demonstrated in several studies in children with OSA with and without obesity at a median average follow-up of 4.9 months after PAP initiation. Research in echocardiographic outcomes is limited, including one RCT in children with Down syndrome and OSA showing no changes in heart rate variability parameters. Evidence of improvements in glycemic and/or lipid control, liver enzymes, and inflammatory markers with PAP therapy is even more limited and of limited clinical importance. Risk of bias was moderate to critical and outcome evidence very low. CONCLUSIONS: Although evidence on effects of PAP on metabolic markers in children with OSA is encouraging, available literature is limited. Longitudinal studies are still required to further assess the long-term influence of PAP on metabolic and inflammatory markers, particularly in children with obesity.

Feasibility of split night polysomnography in children to diagnose and treat sleep related breathing disorders.

STUDY OBJECTIVES: The gold standard test for diagnosis of sleep related breathing disorders (SRBD) in children is diagnostic polysomnography (PSG). This is often followed by a titration PSG to identify optimal non-invasive ventilation (NIV) pressures. Access to pediatric PSG is limited, resulting in delays to diagnosis and initiation of treatment. Split-night PSGs (snPSG) combine a diagnostic and titration PSG into a single night study. Although described in adults, the pediatric literature on this topic is sparse. The objective of this study was to describe a large cohort of children who utilized snPSG to diagnose SRBD and initiate NIV. METHODS: This multi-center study analyzed clinical and PSG data from children with SRBD who had initiated NIV following a snPSG. Data from diagnostic and titration portions of the snPSG were analyzed separately. RESULTS: The study included 165 children who initiated NIV following a snPSG. The majority of children (61.8%) were initiated on NIV for upper airway obstruction. The population included children with medical complexity, including those with central nervous system disorders (17.0%), musculoskeletal/neuromuscular disorders (12.1%), and cardiac disorders (1.2%). Moderate to severe SRBD was present in 87.2% of children with a median apnea-hypopnea index (AHI) of 16.6 events/hour (IQR: 8.2, 38.2). The median AHI was reduced on treatment to 7.6 events/hour (IQR: 3.3, 17.1), with fewer subjects meeting criteria for severe SRBD. CONCLUSIONS: snPSG is technically feasible in children, facilitating the diagnosis of SRBD and initiation of NIV, even in those with high medical complexity.

Does obstructive sleep apnoea contribute to obesity, hypertension and kidney dysfunction in children? A systematic review protocol.

INTRODUCTION: Childhood obstructive sleep apnoea (OSA) is a highly prevalent disorder that may directly contribute to the development of obesity, hypertension and renal injury. Although those associations seem to be clearer in adults, studies in children have revealed conflicting results and updated synthesis of the evidence is lacking. The aim of this systematic review is to summarise the available evidence on the effect of OSA on obesity, systemic blood pressure and kidney function, to help to elucidate whether respiratory interventions to correct OSA would have the potential to improve those outcomes. METHODS AND ANALYSIS: A systematic literature review search was created by a medical librarian and peer-reviewed by a second librarian prior to running. Ovid Medline, Ovid Embase, CINAHL via EbscoHOST, Wiley Cochrane Library and ProQuest Dissertations and Theses Global were searched on 25 February 2020. Titles and abstracts will be screened by two independent reviewers for inclusion, followed by full-text screening of relevant articles. Studies in children will be included if they report data on OSA and weight, systemic blood pressure or kidney parameters. The extracted data will be combined for analysis and the information subcategorised in groups based on outcome. Risk of bias will be determined using tools specific to study methodology and certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach. ETHICS AND DISSEMINATION: This study will provide essential information for healthcare professionals to better understand the relationship between childhood OSA and changes in body mass index, systemic blood pressure and kidney function indicators. Our findings will be disseminated through conferences and publications. The results of this review may guide the initiation of new strategies and the development of future research studies. This research did not involve human subjects and therefore did not undergo research ethical review. PROSPERO REGISTRATION NUMBER: CRD42020171186.

Does non-invasive ventilation change metabolic markers in children with obstructive sleep apnoea? A systematic review and meta-analysis study protocol.

INTRODUCTION: Obstructive sleep apnoea (OSA) is not only common within paediatrics but is associated with critical childhood metabolic morbidity such as obesity, cardiovascular disease and glucose tolerance impairment. Increasing evidence suggests an association between childhood OSA and metabolic syndrome such as markers of cardiovascular disease, systemic hypertension, glucose intoleranceand increased lipid profile. Recent studies have targeted changes in metabolic markers in children using non-invasive ventilation (NIV) but no systematic reviews are available to summarise this emerging evidence. The purpose of this systematic review is to provide systematic synthesis of the evidence on the effect of NIV use on metabolic markers in children with OSA. METHODS AND ANALYSIS: A systematic search of electronic databases and grey literature will include paediatric interventional studies (random controlled trials, cohort studies) with and without a comparison group. Two reviewers will independently undertake the two step process of title/abstract and full-text screening. Data will be extracted and assessed, with aggregate data being reported. When the data allow, meta-analysis will be performed. ETHICS AND DISSEMINATION: There are no ethical concerns with this systematic review, as data have previously been published. This review will inform clinicians taking care of children with OSA and obesity/metabolic syndrome about the potential effects of NIV therapies on metabolic markers and has the potential to change the approach to childhood OSA and obesity. Results of this systematic review will be submitted for dissemination in abstract and manuscript form.

Pneumonectomy in a Child with Multilobar Pneumatocele Secondary to Necrotizing Pneumonia: Case Report and Review of the Literature.

BACKGROUND: Community-acquired pneumonia (CAP) is common within pediatrics and contributes disproportionately to morbidity and mortality. Necrotizing pneumonia is a well-documented complication of CAP. It is thought to be caused by necrosis and liquefaction of consolidated lung and can result in damage to lung parenchyma, including pneumatocele development. Management of necrotizing pneumonia with pneumatocele may include hospitalization, intensive care unit admission, and lengthy antibiotic courses. Severe cases may need invasive procedures. CASE PRESENTATION: We present a case of severe necrotizing pneumonia requiring prolonged venovenous extracorporeal membrane oxygenation (V-V ECMO) with development of persistent pneumatoceles, requiring pneumonectomy while on ECMO support to allow for decannulation and extubation. CONCLUSIONS: In critically ill patients with extensive unilateral necrotizing pneumonia with pneumatocele development, surgical intervention can be considered when attempts to wean ventilation have been unsuccessful. This case provides evidence that V-V ECMO and pneumonectomy is a viable salvage therapy in the most critically unwell children.

Noninvasive monitoring of CO2 during polysomnography: a review of the recent literature.

PURPOSE OF REVIEW: Sleep-related breathing disorders are complex conditions that require the integration of clinical and sleep laboratory findings to support a diagnosis. Analysis of carbon dioxide (CO2) levels during sleep provides important additional information to the clinician that is not obtained from other polysomnographic indices, and that may have a direct impact on both diagnosis and patient mortality. Although arterial blood gas (ABG) is considered the gold standard for assessing PaCO2 levels, there are numerous drawbacks. Noninvasive methods for PaCO2 estimation include end-tidal and transcutaneous monitoring, which allow for continuous monitoring of trends. RECENT FINDINGS: Review of the recent literature suggests that transcutaneous methods correlate strongly with PaCO2 levels and can provide an accurate surrogate in replacement of ABGs. End-tidal methods provide breath to breath information that can be used to assess hypoventilation; however, they have more variability, especially in patients with increased dead space and small tidal volumes. To date, however, there are limited studies investigating noninvasive CO2 monitoring during sleep. SUMMARY: Given the benefits of CO2 monitoring and the importance of assessing for hypercapnia, noninvasive continuous CO2 monitoring should be considered for all patients undergoing polysomnography.

Association Between Chronic Aspiration and Chronic Airway Infection with Pseudomonas aeruginosa and Other Gram-Negative Bacteria in Children with Cerebral Palsy.

PURPOSE: Children with cerebral palsy (CP) are at an increased risk for aspiration, and subsequent pneumonia or pneumonitis. Pneumonia is a common cause of hospital admission, intensive care unit (ICU) admission, and death in patients with CP, and may disproportionately contribute to mortality. The role of respiratory microflora is unknown. This study examined the relationship between respiratory infections with Gram-negative bacteria (GNB), particularly Pseudomonas aeruginosa, and the frequency/severity of pneumonia hospitalization. METHODS: Retrospective chart review of 69 patients with CP and hospitalization for pneumonia. Eligible patients required hospitalization for bacterial pneumonia, at least one respiratory culture, and fulfillment of Bax definition of CP. Group assignment was based on respiratory culture. Charts were analyzed for comorbid illness, hospitalization demographics, and disease severity. RESULTS: Children with isolation of P. aeruginosa or other GNB had increased frequency of ICU admission (77.4, 65.1, vs. 26.9 %, respectively, p < 0.01), intubation (45.2, 39.5 vs. 11.5 %, p = 0.02, p = 0.03 respectively), and large pleural effusions (37.5, vs. 0 %) than children without GNB. Children with isolation of GNB had more prolonged hospitalizations and were more likely to have multiple hospitalizations than those without GNB. CONCLUSION: Colonization with P. aeruginosa and other Gram-negative organisms in children with CP is associated with increased morbidity, prolonged hospitalization, and severity of pneumonia including need for PICU admission and intervention. Further research is required to determine causality, the role of antimicrobials active against Gram negative in pneumonia treatment, and the role of GNB eradication therapy in children with CP.

Review of the CATCH study: a clinical decision rule for the use of computed tomography in children with minor head injury.

CLINICAL QUESTION: In children with minor head trauma, which elements of the history and physical examination, combined as a clinical decision rule, can be used to rule out clinically significant brain trauma? ARTICLE CHOSEN: Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010;182:341-48. OBJECTIVE: To prospectively derive a sensitive and reliable clinical decision rule for the use of computed tomography in children with minor head injury.

Vaccenic acid favourably alters immune function in obese JCR:LA-cp rats.

Vaccenic acid (VA) is a ruminant-derived trans-fat and precursor of conjugated linoleic acid (CLA). The objective of the present study was to explore the effects of VA on immune function in a model of the metabolic syndrome, JCR:LA-cp rats. Lean (2:1 mix of +/cp and +/+) and obese (cp/cp) rats, aged 8 weeks, were fed a control (0% VA) or a VA diet (1.5% (w/w) VA) for 3 weeks (twenty rats per group). Splenocytes and mesenteric lymph node (MLN) immune cell phenotypes (flow cytometry), ex vivo cytokine production (ELISA) and phospholipid fatty acid concentrations were measured. Obese rats had higher proportions of splenic macrophages, total T-cells, helper T-cells (total and percentage CD25+), cytotoxic T-cells (total and percentage CD25+) and produced higher concentrations of IL-6 to concanavalin A (ConA) compared with lean rats. Obese rats had lower proportions of MLN T-cells, new T-cells (CD3+CD90+) and cytotoxic T-cells, but higher proportions of helper cells that were CD45RC+, CD25+ and CD4lo, and produced higher concentrations of IL-2, IL-10, interferon gamma and TNFalpha in response to ConA compared with lean rats. VA was higher in plasma phospholipids and both VA and CLA (cis-9, trans-11) were higher in MLN phospholipids compared with control-fed rats. Lean VA-fed rats had lower proportions of MLN and splenocyte CD45RC+ helper cells, and helper T-cells. Splenocytes from VA-fed rats produced 16-23% less IL-2, IL-10 and TNFalpha compared with controls. VA normalised production of MLN IL-2 and TNFalpha in obese rats to levels similar to those seen in lean rats. These results indicate that dietary VA favourably alters the pro-inflammatory tendency of mesenteric lymphocytes from JCR:LA-cp rats.