This document summarises the conclusions of a European Respiratory Society Task Force on the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and refers to children aged 2-18 years. Prospective cohort studies describing the natural history of SDB or randomised, double-blind, placebo-controlled trials regarding its management are scarce. Selected evidence (362 articles) can be consolidated into seven management steps. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are present (step 1). Central nervous or cardiovascular system morbidity, growth failure or enuresis and predictors of SDB persistence in the long-term are recognised (steps 2 and 3), and SDB severity is determined objectively preferably using polysomnography (step 4). Children with an apnoea-hypopnoea index (AHI) >5 episodes·h, those with an AHI of 1-5 episodes·h −1 and the presence of morbidity or factors predicting SDB persistence, and children with complex conditions (e.g. Down syndrome and Prader-Willi syndrome) all appear to benefit from treatment (step 5). Treatment interventions are usually implemented in a stepwise fashion addressing all abnormalities that predispose to SDB (step 6) with re-evaluation after each intervention to detect residual disease and to determine the need for additional treatment (step 7). @ERSpublications Management of obstructive sleep disordered breathing in childhood should follow a stepwise approach

The present statement was produced by a European Respiratory Society Task Force to summarise the evidence and current practice on the diagnosis and management of obstructive sleep disordered breathing (SDB) in children aged 1-23 months. A systematic literature search was completed and 159 articles were summarised to answer clinically relevant questions. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are identified. Morbidity (pulmonary hypertension, growth delay, behavioural problems) and coexisting conditions (feeding difficulties, recurrent otitis media) may be present. SDB severity is measured objectively, preferably by polysomnography, or alternatively polygraphy or nocturnal oximetry. Children with apparent upper airway obstruction during wakefulness, those with abnormal sleep study in combination with SDB symptoms ( snoring) and/or conditions predisposing to SDB ( mandibular hypoplasia) as well as children with SDB and complex conditions ( Down syndrome, Prader-Willi syndrome) will benefit from treatment. Adenotonsillectomy and continuous positive airway pressure are the most frequently used treatment measures along with interventions targeting specific conditions ( supraglottoplasty for laryngomalacia or nasopharyngeal airway for mandibular hypoplasia). Hence, obstructive SDB in children aged 1-23 months is a multifactorial disorder that requires objective assessment and treatment of all underlying abnormalities that contribute to upper airway obstruction during sleep.

Obstructive sleep-disordered breathing includes a spectrum of clinical entities with variable severity ranging from primary snoring to obstructive sleep apnea syndrome (OSAS). The clinical suspicion for OSAS is most often raised by parental report of specific symptoms and/or abnormalities identified by the physical examination which predispose to upper airway obstruction (e.g., adenotonsillar hypertrophy, obesity, craniofacial abnormalities, neuromuscular disorders). Symptoms and signs of OSAS are classified into those directly related to the intermittent pharyngeal airway obstruction (e.g., parental report of snoring, apneic events) and into morbidity resulting from the upper airway obstruction (e.g., increased daytime sleepiness, hyperactivity, poor school performance, inadequate somatic growth rate or enuresis). History of premature birth and a family history of OSAS as well as obesity and African American ethnicity are associated with increased risk of sleep-disordered breathing in childhood. Polysomnography is the gold standard method for the diagnosis of OSAS but may not be always feasible, especially in low-income countries or non-tertiary hospitals. Nocturnal oximetry and/or sleep questionnaires may be used to identify the child at high risk of OSAS when polysomnography is not an option. Endoscopy and MRI of the upper airway may help to identify the level(s) of upper airway obstruction and to evaluate the dynamic mechanics of the upper airway, especially in children with combined abnormalities. Pediatr Pulmonol. 2017;52:260-271. © 2016 Wiley Periodicals, Inc.

Appendix 1Modelos de consentimiento informado para inmunoterapia oral (ITO) con leche y clara de huevo IDENTIFICACION Y DESCRIPCION DEL PROCEDIMIENTO:Su hijo/a presenta alergia a las proteínas de la leche de vaca. Este tipo de alergia es transitorio en la mayoría de los casos, alcanzando la tolerancia en los primeros años de vida. Pero en algunos casos persiste y permanece durante años con el riesgo de reacción, que puede llegar a ser grave, ante la ingestión accidental de alimentos o bebidas que contienen leche de vaca. Esta situación, obliga a estar pendiente de la composición de los alimentos que puede tomar el/la niño/a.En la actualidad el único tratamiento recomendado para la alergia a la leche de vaca ha sido la evitación estricta de su ingesta, que en su caso presenta dificultades añadidas al ser un producto muy utilizado en la elaboración de innumerables alimentos Existe la posibilidad de adelantar la tolerancia mediante un protocolo de tratamiento que consiste en dar pequeñas cantidades de leche de vaca que se van aumentando progresivamente hasta la cantidad igual a una toma habitual, con la ventaja de que el paciente pueda ya tolerar la leche de vaca o los alimentos que la contengan. Después de finalizar el procedimiento el paciente deberá tomar el alimento todos los días para mantener esta tolerancia.Los incrementos de las dosis se realizaran en el Servicio/Sección/Unidad de Alergología o Alergología Pediátrica donde el paciente permanecerá vigilado y controlado por personal sanitario entrenado en el reconocimiento y manejo de las posibles reacciones adversas que puedan producirse. Estas reacciones pueden aparecer de manera inmediata o al cabo de unas horas, por lo que deberá permanecer el tiempo necesario en observación en nuestra consulta y también puede ocurrir al tomar las dosis en el domicilio por lo que el médico le informará y le dará instrucciones para su manejo y tratamiento.Se llevará las instrucciones necesarias indicadas por su médico así como una hoja indicativa del proceso realizado por si tuviera que acudir a un Servicio de Urgencias. BENEFICIOS DEL PROCEDIMIENTO:Con esta técnica se puede conseguir que el paciente acabe tolerando sin síntomas una dosis habitual del alimento al que es alérgico pudiendo normalizar su dieta y mejorar su calidad de vida al poder realizar una vida prácticamente normal aunque en algunos casos solo se consigue tolerar una cantidad menor de alimento que le protege de la toma de pequeñas cantidades inadvertidas. Siempre va a exigir la ingesta habitual y frecuente del alimento. RIESGOS GENERALES Y ESPECIFICOS DEL PROCEDIMIENTOEsta técnica no está exenta de riesgo ya que frecuentemente se producen reacciones alérgicas generalmente leves.Riesgos poco graves pero frecuentes: enrojecimiento de la piel, urticaria (ronchas) alrededor de la boca, picor de boca, hinchazón de labios, hinchazón de párpados, dolor abdominal, vómitos aislados, tos, congestión nasal , enrojecimiento y picor ocular.Riesgos graves poco frecuentes: vómitos y diarreas intensos, dificultad para r...

A clinical practice guide is presented for the management of OIT with milk and egg, based on the opinion consensus of Spanish experts.